December 10, 2014
Secondary to strain that dental braces caused on my front tooth while pulling it into straight alignment, the nerve root was cut off the tooth subsequently started turning yellow years later. My regular dentist was able to bleach my tooth from the the inside every 4-5 yrs. for about 25 yrs. however, a crown or implant were inevitable. I reached that road-point this year. I am 44 and my dentist of about 8 yrs. recommended a crown. I had a crown placed about 4-5 months ago. Since then, it came off once, he put it back on. The second time, it came loose but didn't come off, my dentist office worked me in but not with my regular dentist. She worked on removing my crown for a while but was not having success. She didn't attempt to seek assistant from a senior dentist but got more aggressive with removal and that was when we heard my front tooth snap. There is not enough tooth to attach the crown back on, and I have no choice now. I have used up half of my dental benefits for the crown already this year. And the implant will be around $3300.00. Is my dental office responsible in any way for any part of the implant?
Interesting. First of all let me preface by stating that I am not a legal expert, so from the standpoint of the law I can't answer. So... from a technical standpoint, I would say no. In my experience, I have never once seen a tooth break at the gum line unless it was weak to begin with. That being said, in my office, I probably would take care of you... but that's not a "I'm required to take care of you" kind of thing, but more of a, that's just the type of person I am.

My best advice is to speak to the senior dentist and the office manager, let them know what happened and the senior dentist may agree to keep a patient who's been around for eight years. To me you are the best type of patient. We have built a trust and good working relationship.
Q&A - Failing Restoration
August 8, 2014
Hi... I'm 28 and at a crossroads... my whole life I have felt my mouth worth any investment... however, recently I have had an experience that makes me want to give up on even trying to maintain them. A couple years ago I had a rood canal with an inlay, crown inlay I wanted the strongest on my molar, my dentist told me the inlay would be just as strong as a gold crown. So a year after the inlay, severe pain, and I mean pain that novacaine and getting the site drilled out daily for 4 days in a row didn't even touch, like suicidal pain, when it turns out the inlay had cracked? And infection had proceeded deep into my gums/jaw.... misery.... so the dentist and oral surgeon worked hand and hand to put me right, at no expense to me. Three months later the inlay falls out? Dentist does it again.... falls out within a week... dentist says not enough tooth left to securely attach the inlay and now it needs to be pulled and a permanent implant put in... I can't get a straight answer from the pair of them but hoping you can help, had I originally had a crown put on the tooth would I have experienced the same problems or was this just destined to be my $5000 tooth?.... I'm just frustrated and confused why I invested so much in a tooth that has to be pulled because the dentist ground it too short for the type of treatment he applied, the inlay....
The answer is maybe, maybe not. Inlays are generally very successful. Without seeing the tooth myself it is really impossible to say. That being said, even the best of crowns can fail. Oddly enough, the worst of crowns can also do just fine. It depends on so many factors, too many to list here. Personally I am a big believe in crowns over root canals; however that doesn't mean you were dealt a bad hand. Sometimes things happen. Generally speaking, whenever you have a root canal done, then a crown (rather than an inlay) is indicated. That's what I would have gone with.
Q&A - Broken Tooth
April 15, 2013

I had a crown put on one of my front teeth about 5 month ago - I had injured this tooth and had a root canal as a child, and the tooth had always been slightly crooked and discolored, especially around the gums. My dentist said a crown would solve this.

Well, yesterday as I was eating a piece of hard chocolate my tooth fell out - the crown was still intact but the tooth that my dentist had shaved down to do the crown had actually broken off - it was still stuck in the crown. So now I am left with no tooth whatsoever to work with. I am visiting my dentist today some time and assume I will be told I need an implant, which I know is very expensive. As the shaving down of the tooth and crowning was his work, does he have any obligation to cover some or all of the cost if I need an implant?

I am extremely upset over this and have friends telling me the dentist is responsible for fixing this, but I often have a hard time sticking up for myself in that way. Please let me know as soon as you can what should take place in this situation.

Thanks so much.

You are in a tough situation. Personally I can't imagine a well made crown would cause the tooth to break or fall off unless something with the tooth already existed. Crowns are generally very reliable. From the legal perspective there is no medical or dental procedure that is ever guaranteed. So legally he doesn't owe you anything.

That being said, when you perform a root canal on a tooth, you remove the blood supply which over time makes the tooth brittle and more likely to fracture. I would suspect that this is the reason the tooth broke. This is kind of like putting a tire on a car with a weakened axle. The tire that is placed is fine, but the axle breaks. It probably was going to do that anyway regardless of the tire. There are absolutely no tell-tell signs that would suggest to us a tooth is about to break. Your dentist cannot predict fracture.

From a "being nice" perspective, in my office I would apply the cost of the crown to the implant if it was done recently, sometime within the past two months. At 5 months I can't imagine a stable crown could cause your tooth to break. As much as it hurts, I don't think the crown did the damage here. Now whether your doc will help you out or not is a matter of choice, those implant parts are very expensive for the office to begin with but just be honest with the dentist. I know I appreciate honesty and I tend to be more willing to help people who are just upfront than people who like to make up stories and play games. You'd be surprised sometimes.

Q&A - Missing Tooth
January 7, 2012
Dear Honest Dentist,

I came across your blog while searching for answers for my dilemma. I have a lost a molar tooth last year due to bad root canal years ago. My honest dentist (retired now) removed it due to bone loss and impacted tooth. Now, a little more than a year later, I switched two dentists (all seem to be pushing lots of fillings and panoramic xrays every 6 months) I am wondering if that gap needs a crown (is it abs necessary?). My insurance doesn't cover anything of that sort, so it will be an out of pocket cost... that I can't afford.

The gap is in the back where a tooth away from the lower wisdom tooth (#?). I already lost bone from the previous, so now the xrays show less bone than others, that's clear, but dentists now think I have lost that much bone already.

I am comfortable with a gap there, would it be okay to leave it there? I don't mind the shifting, since the wisdom tooth there is crowded and could use some room of shifting.

Thank you in advance for your help.
It really depends on the situation. For the most part, if you have had your tooth missing for a long time, and have had absolutely no complications, then I would say it is not absolutely necessary. I do, however, recommend replacing the tooth. If it were my mouth I would always replace a missing tooth. There are several reasons for this, better chewing, better distribution of bite force and prevention of super-eruption of opposing teeth and shifting of the teeth surrounding the space. Basically having a tooth there generally protects other teeth from damage.

Should you decide to replace the tooth then there are several options out there, ranging from cheap to expensive. By far the best option (and most expensive) is an implant, followed closely by a three unit bridge. The cheapest option is a partial denture, and I generally only recommend this as a temporary option until you can afford one of the first two.
Question and Answer
August 2, 2011
In November I had a crown put on my number front number 8 tooth. I got it because my tooth had been a little slanted from sucking my thumb when i was young. The dentist basically just shaved down the tooth and i got the new crown a few weeks later. About 3 weeks after my crown was put on my tooth was really sensitive to hot and cold. I was told that was normal for the first few weeks. About 4 months later my tooth was hurting so bad that I had to go to the E.R.! The next day my face swelled up and I was out of work for five days. When I went to another dentist (not the one who did the crown they told me that my tooth was infected and that I would need a root canal and a new crown. I was asked how could this happen? She told me that I had an open margin and it was from the crown not being placed properly. I called the dentist old office who did the crown and I told the office manager the situation. I told her that I deserved my money back because for his mistake I have to pay for another crown and a root canal. She said that once the crown was in my mouth it was my responsibility. I told her it was a failed job. She then said that is my opinion and I told her no it was a fact!! Is he liable for this? shouldn't he pay? I saw the xray and the open margin is big.
Short answer, yes. He should pay for your crown, or at minimum refund you the cost of the original crown. Then you leave it at that and things are done.

Now, for the long answer. From a legal standpoint, you may not have a case, but this depends on which state the practice is. All have different laws. There is no procedure, medical, dental or otherwise that does not carry risk of further complications. This is simply the reality of healthcare practices. I would highly recommend, before anything, talking to the dentist in person rather than speaking with the office manager. I believe he would be more understanding of your situation. In my experience, office managers only see money. If that doesn't work, then you have a couple of options, both of which require you to have your dental records with you. You can file a complaint with your state's dental board examiners or file a lawsuit. Dental board examiners generally is the better way to go. I never recommend a lawsuit because usually it benefits lawyers more than patients and in general increases the cost of healthcare. Part of the reason that healthcare costs sky rocketed in the US is simply because society has become much more litigious. But that's a whole other story.
Wisdom Teeth, Do They Really Need to Come Out?
July 15, 2011
The short answer is it depends. In the scope of my practice I have seen many many wisdom teeth that just dentists and oral surgeons want to pull out. Most of the time, yes, they do need to come out. Other times though, wisdom teeth aren't doing any harm and they don't look like they will. At that point, why pull them out?

The thing to watch out for would be group practices that employ oral surgeons or even private practices that employ oral surgeons. Basically if you're fifty years old and have had your wisdom teeth and they're not causing any problems. The likelihood of them causing problems in the future is very very small. I would say not worth the price and hassle of removing them.
Dental Therapists
June 5, 2011
I just read an article discussing preparations and recommendations for a two year curriculum for a dental therapist position. Essentially, a middle man between you and your dentist, who does the work your dentist recommends. I'm a big fan of your dentist turning into a role closer to a family doctor. You discuss your problems, get a checkup and get diagnosed. Any work can be done by a "dental nurse". Why not? It can make fillings much cheaper to perform and really benefit the general population. Reducing the fees allows greater access to care for people who simply couldn't afford it prior.

My only issue with this is really the liability factor of it all. Would you allow a middle man to do heart surgery on you? I would imagine not, I wouldn't. Even a trained one. I don't see how this would be any different. When I first heard about this I was very excited. The prospect of a doctor doing what doctors should do, diagnose. But then I remembered my training and how I am not simply a doctor of dentistry, but also a surgeon of dentistry. DDS stands for doctor of dental surgery. To take the surgical away would be a difficult pill to swallow. I suppose some procedures, like simple fillings would be the scope of a dental technician (nurse). More complicated procedures would still be performed by your dentist.
Honest Dentists
May 28, 2011
As recently as two days ago, I was again presented with a very nice and trusting patient who "needed" 13 fillings. Taking a closer look at the matter I had noticed that the patient has never presented with a cavity before. In fact, her teeth were textbook flawless. I am embarrassed by the profession sometimes and where it is going these days. It is true that it is very difficult to find a trust worthy and honest dentist. As dentists we need to be more diligent to educating patients and weeding out the dentists that give us a bad name.

To be alright with cutting away tooth structure and simply taking advantage of people is beyond me. Word to the wise, if you have always had regular checkups and never had a cavity in your life, be sure to get a second opinion when you go in one day and all of a sudden have thirteen. That is an obscene amount of cavities in today's world of Fluoride toothpaste.
May 18, 2011
In the past week I have done several enameloplasty cases. It just seems to have worked out that way. A simple, painless and as long as it's carefully done, almost full proof procedure that turns chipped ugly teeth into shorter and more beautiful teeth. As with any procedure, case selection is extremely important. The results have been absolutely stunning. These patients lost at least 10 years in dental age yet didn't get a single shot and stayed no longer than half an hour. These are the same patients who have wanted better looking teeth but were only offered the option of placing veneers. In my case, I tend to do veneers as a last resort.

These same particular patients were quoted almost 10k worth of treatment to veneer their upper teeth. Oddly enough, this is something that I see often in my practice. Most of them have normal teeth with some basic chips and small misalignments. Something I would hardly recommend a whole set of veneers for. Instead I prefer to do something much less drastic, an enameloplasty. A procedure where I recontour your teeth by shaving off slight amounts of enamel (much less than what you would for veneers). It causes no sensitivity and takes a fraction of the time. Not only that, the results are more natural than veneers (because they're you're real teeth) and it only takes minor adjustments to have a huge result. Best of all, I charge about 1200 an arch. A much cheaper price tag than doing veneers.

In the past couple of weeks I have done eight cases of enameloplasty. Every patient was very highly satisfied and the cost savings to them were significant. Not only that, these are their real teeth, they will maintain them as they always have. They simply look better.
Products, Sales and Dentistry
April 16, 2011
Lately I have been finding myself in the middle of a lot of conversations involving selling stuff to people. Pushing products on people. A practice that I am not a huge fan of. I understand the necessity for people who need a certain product, but I just can't imagine every patient needing every product that is offered in my office. This is a practice that I despise. The idea of turning dentistry into a salesman position is appalling. Where is the honor in treating people? That being said, this is a practice that will not be happening in my office. I am not here to sell stuff I'm here to treat.
Periodontal Disease and Laser Treatment
February 19, 2011
I have just finished a class on Class 4 lasers and their use in soft tissue management and periodontal therapy. As it turns out, there is a lot of science behind what I have been recommending in my practice. Periodontal disease is a relatively new "thing" in dentistry. I mean that in the overall sense of dental care. It used to be where it was simply acceptable for an aging person to start losing teeth. By the time you reached your fifties or sixties dentures were the norm. Almost expected.

Periodontal (Gum) Disease is the most under diagnosed and least treated condition of the oral cavity. Some estimate that as many as 75 percent of Americans have periodontal disease. Now imagine a house, where if you break a window you replace it (cavity), or you find a crack in the wall and repair it (crown). Now imagine if your entire foundation is completely failing underneath it, getting softer and softer as time passes. Eventually the house will no longer survive. This is exactly the case with periodontal disease, where the bone that is supporting the tooth is slowly being dissolved away. Yes it is this serious, not to mention its relation to diabetes, cardiovascular disease and other serious system illnesses. In addition, perio disease is a life long condition. Once you have it, you have it. It is important to note as well that at this time, there is no way of reversing the disease.

So why is this disease so elusive? Well stubbornness mainly. Imagine a doctor who has been practicing for forty years. Never trained in gum disease because it simply wasn't important. This formula has worked for forty years, why bother changing now? So as with any profession, dogma will have to be changed. Gum disease is proven with sound studies and treatment should be taken seriously. Very seriously. This brings me to my next point, what should the treatment entail. I will keep this quick and simple. In my practice, patients who present with periodontal disease go through an initial treatment of scaling and root planing (deep cleaning), chlorhexidine debridement, laser treatment (more on this in a bit) and three month follow up cleanings. Let me explain the importance of each step.

Scaling and Root Planing - truly the basis of any gum treatment. Simply put you have to remove as much tarter and bacteria from above and under the gums as you can. This requires anesthesia and is really much harder than it sounds. Now, once you have the large bacteria out of the way, you go to the next step. Here you use a medicated mouth rinse to kill any bacteria that is hiding and also promote a healthier tissue response. The next step is laser therapy. In my office I have always seen an amazing result with laser therapy. Until today, however, I have never understood the mechanism behind it. Simply put, scaling and root planing followed by chlorhexidine simply cleans the bacteria out and removes any from the tooth tissue. None of it addresses the gum tissue and the bacteria that is actually infecting your gums. This is where the laser does an amazing job. It kills the bacteria in the soft tissue as well which improves the prognosis for the treatment dramatically. In my practice I have seen 11mm pockets go down to a healthy 2mm reading. Something that prior to laser would simply be unheard of. Prior to laser if you can reduce an 11mm pocket to a 7mm you got excited. For reference, 3mm and below is considered healthy. This now brings me to the last step, that is maintenance. It is of absolute importance to go back to the dental practice every three months for a perio maintenance. It costs a bit more and takes a bit longer than your average cleaning but this is the best time to go back and keep your mouth clean. Studies show that while you can remove a large amount of bacteria, you can never truly get rid of it. They also show that the bacteria takes about three months before it grows back in large enough numbers to cause symptoms of the disease (bleeding gums, bone loss, mobile teeth) again. If you remove the bacteria every three months then you are going to reduce the load and prevent any further symptoms from happening. This way, while you can't reverse the disease, you at least prevent it from getting worse.

So that being said, there is a down side to this as well. It seems a lot of practices love to use periodontal disease in the diagnosis so that they can charge a hefty fee for a "deep cleaning". It's easy to do since it's a relatively unknown disease. I am amazed by the number of people who come into my office and are "diagnosed" with perio disease. While I accept that a large amount of the population will have a form of it, I certainly don't believe all of it will. Second opinions are important.
J Morita - Taking Radiation Seriously
January 26, 2011
As a quick follow up to the last post about cone beam CT machines and possible radiation dosage, I have today read an interesting article on Dr Bicuspid about J Morita. Turns out J Morita takes cone beam CT scans very seriously, as well as the radiation exposure that these machines can produce. If compared with a full set of dental x-rays, most cone beam ct machines actually produce less radiation. But as compared with a single x-ray, the cone beam will obviously produce more radiation. J Morita has claimed that their machines produce less radiation than most. Today they announced that they have managed to reduce radiation levels by as much as 30 to 40%, without distorting the images and also producing a better soft tissue profile. I believe that they can backup their claims with hard facts as well. This bodes well for all cone beam CT fans. Also for patients as well, being able to have quicker and much more comfortable single scan, rather than eighteen different xrays is a time saver for the doctor and the patient. In addition, a much better scan, clinicians will be able to provide a much better and more accurate level of diagnosis. Root canals can easily be visualized ahead of treatment for a more predictable result. This is the future, I'm just glad that there is a company out there that does not downplay the importance of radiation safety. I am also glad that there are enough honest dentists around for the manufacturer to consider radiation safety to be an important factor.
Kids! Watch Out For Radiation
December 19, 2010
The New York Times released an article to raise concerns over just how much radiation is being used on your children today. Many dentists have taken this article as a scare tactic by the news to increase subscription. Turning a complete blind eye to the fact that radiation is in fact harmful. It is especially harmful to any developing body, in other words, while adults might not have too many issues from being exposed to a little extra radiation, children can be adversely affected. There are reports where children feel tired after being exposed to some radiation, although the vast majority have so much energy to spare I doubt they would feel the difference. Of course, this doesn't mean that no harm can be done to them either, radiation does not work that way. On the other hand, radiographs are necessary. Not too long ago I was writing about the advancement with cone beam CT and how standards of care will change. This is still true although I would caution agains the blind use of cone beam CT machines. The advancement is great, however, just like any other tool in the dental field, it should be used with respect to the risks and with proper indication. Also if possible, use should be limited to adults, where the risk is much lower.

With the exception of orthodontics and some oral surgery cases, I just cannot see a need to use a cone beam CT machine on children. Children really should be limited to 4 bitewings and a panoramic x-ray. The panoramic is used to look for growth patterns and any possible future problems while the bitewings are used to find the most common decay found in kids. Some oral surgery cases might warrant the use of a cone beam CT scan, but all surgeons should be able to gather the information they need from a panoramic image. As far as orthodontists are concerned, I would suggest a cone beam scan for only the most complex cases. The New York Times article mistakenly compares cone beam in an orthodontic practice to a single panoramic image, yet the article fails to mention a cephalometric scan which also exposes children to a lot of radiation. In some cases if you combine the panoramic scan and the ceph scan they might equate to more radiation than a cone beam scan would and not provide nearly as much information as a cone beam scan would.

In the case of adults, I see most offices converting from a panoramic machine and the small x-rays to a single cone beam scan to look for problems. This also worries me a bit. Most cone beam manufacturers claim that the radiation is lower than a medical CT scan. This is true, however, most are currently not lower than radiation doses from a full mouth series and a panoramic, the standard in dentistry. I say currently because most cone beam manufacturers are working very hard to try to achieve a lower radiation dose. In fact, J Morita claims that their machines are already there. I would like to see the studies behind their clam, but if it is really true, I would be inclined to replace my panoramic machine and full mouth x-rays with a cone beam unit from them. What patient wouldn't like the idea of a quick 14 second scan over the individual and usually uncomfortable x-rays? What doctor would not like to expose their patients to less radiation and yet be able to have much more information available? The diagnostic capability of cone beam is a very big step forward for dentistry and for patients alike.
More on Stem Cells
November 15, 2010
While I have had a lot of interest in stem cells and their potential for repairs. I came across an article showing only one of the uses of stem cells. Repair vertical bone defects caused by stem cells. I don't have the research study itself, but if the results do hold true, then this is an amazing feat to accomplish. Repairing vertical bone defects has been one of those problems in dentistry, where you simply would normally think you are beat. With this stem cell solution, it would be a relatively easy process to repair bone defects. Imagine what you can do for a person, who previously, would have to have several teeth pulled out due to gum disease now you can just regrow the bone and save the entire mouth. Incredible.

A quick note I would like to mention is that the linked article is from a report made by StemSave, a company that specializes in collecting extracted teeth and storing the stem cells. So when you read it, tread very carefully as sometimes these can be biased.
Dental Technicians, Milled Ceramics, Cone Beam CT and Standards of Care
September 4, 2010
The future of any profession is in constant evolution. Small changes here and there, and over a period of time you will see an entirely new business model. This is a reality of any successful business and any good management. Today this change is very evident in dentistry. One of the biggest changes that you will see will be the delegation of many of the small dental procedures to a "dental technician". What this means is that although your dentist is still able to perform these services, most likely he will diagnose you and have someone else perform the work on you. Currently there is a very large debate on the subject of allowing people do what is today considered a "dentist only" procedure. Yet we as dentists forget that not too long ago, the idea of having a dental hygienist was just as revolutionary as what is being considered today for a dental technician. When I first heard about this proposal I was instantly against it. Not for any logical reason but simply due to one thing. I am used to doing all the work. However, as I began to cook the recipe of a dental technician in my mind, I realized that this is in fact a great idea. This will change the dental model as it is today to more of a medical model. A dentist diagnoses (as he should) problems and the technician, which to me is synonymous with a nurse, would handle the treatment. This will allow a couple of things to happen. Bring prices down and treat more patients at the same time. Certainly not a very bad thing. Of course, the overhead of the office will increase significantly, so things like free cleanings or free exams will most likely disappear. But any work that needs to be done, will most likely drop in price.

As hot of a debate as it is to have someone other than your dentist do your work, seems like the gold standard is not going to be gold for much longer in dentistry. For many years, and many older dentists, there is no better restoration than gold. It is the absolute longest lasting restoration you can have placed in your mouth. However, times are changing and technology has been helping dentistry in many different ways. As of recent studies, it seems that all types of milled ceramic restorations have been shown to outlast gold restorations. In fact, the highest retention rate of gold for ten years has been about 87%, while the retention rate of milled ceramics for ten years has been over 90%. This is going to change the dynamics of dentistry, from lab based solutions to in house, one visit, CAD/CAM milled ceramic solutions. With research to back these up, this will truly be the new gold standard in dentistry. What this means is that it will be used more, prices will likely go up a little but insurance will do more to cover the fees for milled ceramics. Overall this is a great thing, it truly is a better product for patients. It will be a heavily debated topic and likely many dentists who have been doing gold dentistry for a long time will simply dismiss the evidence.

Milled (CAD/CAM) ceramics are not the only advances that dentists are getting. Cone beam CT scans are quickly becoming standard of care. Seems like every office I talk to about cone beam CT gets very excited. This is true for dentists as well as oral and maxillofacial radiologists. Heck, all the other specialties as well, but I'll only talk about those two. Cone beam CT is changing the game in dentistry to allow for much better diagnosis, much more accurate readings and eventually the complete replacement of oral alginate impressions. What that means is that the gooey impressions that your orthodontist takes, or your dentist takes for study models will be gone. Instead a cone beam machine will simply do a scan in less than 30 seconds (most are already much faster) and produce a very high resolution 3D model of not only your mouth and your teeth, but also head and neck, TMJ and soft tissue structure. Currently you can design implant cases on this model, but in the future you will be able to design full mouth restorations. This new method of x-ray might also be diagnostic enough that it is possible to accurately diagnose decay and replace traditional full mouth x-rays and bitewings.

For oral and maxillofacial radiologists (head and neck radiologists), they are more interested in disorders, cancers and tumors. As a patient you should always ask your dentist for a regular, yearly head and neck cone beam CT scan and having him send it to an oral and maxillofacial radiologist for hard tissue cancer screenings. This service should be done regularly and yearly. The technology produces less radiation than full series of xrays and is much more comfortable. True dental insurance probably will not currently cover it, however, for about 300 dollars a year, it really isn't such a large investment and will do to head and neck hard tissue cancer what yearly mammograms have done for breast cancer. Save lives!
Cosmetic Dentistry and a Little More on Insurance
June 13, 2010
Browsing the internet today, I ran across a website for people who are worried about being over-treated and for people who are dental phobic. I decided to take a look at the content and see if this is something that might be helpful to me as a dentist in treating people who do not like being at a dental office. In my line of work not only must I be a good dentist, but also a good psychologist sometimes. I make no claims in psychiatry but the fact is, making people comfortable at a dental office is one of the biggest challenges you can meet. This is especially true for a dentist such as myself who does not believe in using Nitrous sedation or prescribing mind altering sedatives prior to treatment. I have nothing against those methods but I do feel that if you are good at your dentistry and treat each patient with care, the rest takes care of itself.

Continuing on, as I was reading some articles listed on this site, I came across two that I thought were interesting. First as an addition to my last post on insurance, the site essentially agrees with what I had said previously about dental insurance, and that is generally it is not a great idea. Personally I feel that the best practices around and the best dentists are the ones who practice in a fee for service model. If you need work, you pay for it. It is that simple. It also ties in on patients being over treated or under treated due to the service fee agreements that these insurance companies negotiate with the dental office. At this point, I do not own my own practice and work for a company that offers DMO/PPO discount plans. I recommend the dentistry that I think people need and to be honest, I am barely scraping by financially. On paper the idea of these types of plans looks great, but in reality they almost force a dentist to let the insurance company dictate what type of treatment is appropriate for the patient, and this is always a bad idea. If you want a fair dental treatment, I suggest finding a dentist who is only fee for service. Also you may consider reading the article that I read. It does have some solid advice.

Another article that I thought is a good read is about "cosmetic dentists". This article discusses the practice of replacing metal fillings with composite fillings. A practice that I personally consider to be poor for patients. I have always considered myself to be a cosmetic dentist. In today's age and time, where dental aesthetics are in fact important, this is a skill that is required of dentists. We live in a cosmetic age. That being said, I still do not think that removing perfect amalgam fillings and replacing them with composite ones is good practice. Fixing something that is not broke will probably cause more problems than it is worth and unless the amalgam filling is in your smile line and just blatantly obvious, I almost always refuse this type of treatment for several reasons. Every time a filling is removed you irritate the nerve of the tooth. This increases the chance that the tooth will require a root canal and crown. Also each time a filling is replaced, you remove more tooth structure, making the filling bigger and bigger. This means that the tooth has a higher chance of requiring a crown in the future. Another and very important reason for not replacing a metal filling with a composite filling is technique. While any dentist these days can put a composite (tooth colored) filling in a tooth, the majority do not do it properly. It is very technique sensitive and requires more equipment.

Additionally, I think a fine line exists between cosmetic dentistry and traditional dentistry. There is a large debate in the dental community when it comes to cosmetic dentistry. I have met dentists who swear that it does not matter what people's mouths look like as long as they are healthy, I have also met the other end of the spectrum where every person needs a bleaching and six veneers. Just like with anything else in life, there is a fine balance and it is usually somewhere in the middle. I believe that the mouth should be healthy and at the same time aesthetically pleasing. This does not mean bleach and veneer every patient nor does it mean ignore patients who are interested in prettier teeth. What it means is that if a tooth has to be repaired, then ideally a long lasting restoration that is aesthetically pleasing is generally the best option. People do care how their smile looks as much as they care about how healthy their mouth is. Dentists who only want to fix a problem and don't care about cosmetics really do not consider the patient as an entire human being, but merely a mouth. Dentists who want to bleach and veneer everyone without regard to health shouldn't be dentists at all in my opinion. The best dentists out there are the ones who consider both the person and the mouth that they are examining. Go to a fee for service practice and find someone who you can trust. A second opinion never hurts. As a last piece of advice, never let anyone pressure you into treatment and never ever let your insurance company dictate what treatment you need.

If you have any questions or comments, click on the email link above and shoot me a message.

The Benefits of Insurance
May 18, 2010
Many times a day I meet patients who are surprised by what is in fact covered by their insurance company. More than anything they are surprised by what is not covered. "Why do I even have insurance?" seems to be a very common question in the dental world.

Sometimes I ask myself the same question. As a dentist I have no dental insurance. I have never seen the value of it. If you add up all the monthly payments made on dental insurance and add up all the work that an average patient needs to have done, more than likely the money spent on work is less than money spent on having an insurance policy. In addition, when you do have an insurance policy, more than likely it does not fully cover most of the work that you need.

I think the word insurance is very misleading. Part of the word insurance gives people a sense of false hope. That if something were to happen that their insurance company would financially support them through their hardships. This of course is false. Insurance is a business. Just like any other business, they are interested in making a bottom line and a profit. So while an insurance company might promise you peace of mind, they also fail to let you know that you have a $1500.00 limit on that peace of mind and that it is a partial piece of mind. If anything, the term "insurance company" should be replaced with "policy company". A group of people who contractually offer you discounts on prices for a fee. Similar to joining a Sam's Club or Costco. Essentially providing you dental services at wholesale prices but limiting how much product you can purchase.

So why have insurance at all? This is a tough question to answer. Personally I have no dental insurance. I would rather find a good dentist to recommend treatment for me and pay full price for fillings or crowns than to pay a consistent salary to some insurance company for the rest of my life.

As an aside, the best insurance that anyone can have is proper oral hygiene. That means meticulous brushing/flossing, good eating practice and a great dentist.

Tooth Regeneration
April 24, 2010
Today as I was getting a patient numb and ready for treatment, we went into conversation about teeth, the future of dentistry and what will be possible. My patient asked me if it at all would be possible to regenerate teeth. To grow them as simply as you would a plant.

In the back of my head I knew there was research happening in this area. So I began looking a little deeper into things. Turns out we are not that far away from this reality. Several research companies and universities in many different countries have inched closer to producing fully developed teeth. In fact, one group in Japan has managed to grow a full tooth in a rat. The methods are not clear to me yet, but it seems that stem cells are extracted from wisdom teeth (or baby teeth) and are given a specific signal, that tells them to differentiate into a tooth. These cells are then implanted into a patient and after some time a tooth starts forming. The practitioner can choose a molar, an incisor, premolar or canine. The tooth forms fully with nerve endings, normal sensation, look and feel. Only a few key issues are stopping tooth regeneration from becoming a reality.

First, stem cells are required for this process. Fortunately they can be taken from the patient's own teeth, so no controversy involving embryos here. The problem, however, is that many people have already had their wisdom teeth extracted due to impaction. So if you are missing all , you might be out of luck. The second issue in this process is that these teeth tend to grow smaller. While in the posterior area this might not be as big of a problem, on anterior teeth, this is going to be a significant issue. Researchers are currently working on why this is happening and they are attempting to find a solution. The third problem is growth rate. To clarify this let me very simply explain the time it takes human teeth to fully develop.

Human teeth take roughly nine years to develop from beginning to end. Dentally speaking, teeth develop in three different stages, each taking 3 years. Starting with a cyst and ending with the root tips. While this is expected in normal human growth, in terms as seen by a dentist, this is completely impractical. In order for practitioners to implant teeth in a timely fashion, the tooth regeneration process must drastically become faster. I would suspect that ideally you would want development to take about six months. The reason for this is that regeneration might also stimulate bone growth which in most bone grafts is usually a six month process. This would essentially fix two problems with a simple implantation.

So when can we see this become a reality? There are many different points of view on this. Many people are suspect of the entire procedure, whether it can work in humans or not. No human testing has been done as of yet. Most estimates place us anywhere from 5 to 10 years before regenerating teeth becomes a reality. For me, this seems like a very bright future. There is nothing I would love more than to extract a tooth, implant a new one and six months later my patient has a brand new, very healthy tooth. The only requirement is that you have stem cells from your teeth. For this you can use a storage lab like StemSave.

To Go All Ceramic or Not
April 14, 2010
In the past year or so I have gained a lot of experience in all ceramic restorations. CAD/CAM dentistry done in one day. Crowns, inlays, onlays, simple one tooth restorations to full arch restorations. From the simple to the very complex. While in dental school we were introduced to all ceramic dentistry. A little background first. Out of four years of education, two of which were strictly clinical, we spent an entire half an hour learning about all ceramic restorations. How to image, design and build a crown. Lucky for me I am very tech savvy and learn things quickly. For most students, however, CAD/CAM dentistry was nothing more than a simple introduction to what could be in the future. Nothing to take seriously as of yet and mainly something to ignore.

Fast forward a few years later. Here I am practicing almost strictly with all ceramic crowns. In my office, if a patient needs a crown, I almost always prefer to use an all ceramic crown. My preferred system is the Sirona system which produces the name brand Cerec crowns. That being said, it is time to tackle the subject at hand. What is a better crown? These days you can find dentists arguing for both sides, ones for traditional, metal based crowns and others for all ceramic restorations. So what is the difference?

Simply put, it is the material involved in making the crown. Sometimes the process as well. Traditional crowns use a metal base to fit on the tooth and then porcelain placed on top of them to try to make them look like teeth. All porcelain crowns are just that, all porcelain. Traditional crowns are believed to be longer lasting, this I think is a myth more than truth, while all ceramic crowns are more cosmetic. So which crown should you choose?

It truly depends on your situation. Both crowns are excellent options, if you have a little bit of extra money I would say go with an all ceramic restoration. While it is true that the metal layer in traditional crowns is stronger, the porcelain that is laid on top is very weak. Breaking that means that the crown is ready to be replaced. Also since metal loves heat, it tends to shrink and expand in cooler or hotter situations, such as eating ice cream or drinking a hot cup of joe. These properties cause the cement to fail underneath the crown and open margins to develop. Open margins are not cleansable, which causes them to decay and rot the tooth underneath. This compared with a CAD/CAM all ceramic crown, which tend to have a much more accurate fit and in my opinion protect the tooth much better than any metal based crown. Also the porcelain used for Cerec crowns is anywhere from 3 to 8 times stronger than that used on a traditional lab fabricated crown. This makes these crowns more resistant to fracture and break. Ideally, this are the features that you want to find in your next crown. To help you make the decision also as to what type is better, you really have to consider which crown your dentist is comfortable in making. Cerec crowns are very technique sensitive, and if done improperly will almost always fracture prematurely. On the other hand if done correctly these crowns can last a very long time.

Which crown you choose is going to be a personal decision. In the end you will have to weight several things. Finances, longevity, strength, fit and finish, aesthetics and yes... dentist preference. If all else fails, you can always get some more explanation from your dentist as to what works best in his or her hands.
A Blog With Purpose
April 13, 2010
Today marks an important chapter in my life, where as a dentist I am beginning to notice the good from the bad. I decided to write about my experiences, give advice when I can and answer any questions that may arise. There are so many questions that simply go unanswered. Treatments and the logic behind why some treatments are recommended. I hope to clarify why dentistry is like every other medical field and not at all like any other medical field. I am also hoping to denounce general myths about dentistry and remove the stigma behind dentists.

What you should know about me. I am a dentist. I consider myself honest. I have experience in traditional dentistry and newer, more modern dentistry. I am here to help, so feel free to ask or even send an x-ray with a question or two.