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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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!
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.
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.
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.
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.
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.