Are online reviews helpful to your dental practice?

They have been good for my dental practice. New patients regularly comment that they have read my patients' online reviews and that was one of the factors that made them decide to come to my office. I am fortunate that for the most part patients who have written online review have said positive things about my practice and my staff. When I do a google search on my name, the first page lists a number of sites offering reviews of my dental practice. I should add that I generally am not afraid to ask patients, who seem happy with my services, if they would like to write a review of my dental practice. I explain that good word of mouth is the best way attract new patients and if a review is posted on the internet, it may be viewed by thousands of potential patients. Of course the converse is also true ,since one angry patient's rants can also be heard by an equal number of potential new patients.

Why doesn't dental insurance cover extensive dental costs?

Probably because if dental insurance covered large dental expenditures it would be necessary to raise everyone's premiums to an unacceptable level. Instead most dental insurance policies are set up quite differently from medical insurance plans.

While most medical insurance plans cover a  patient for hospitalizations and will pay a high proportion of a patient's doctor and hospital bills, most dental insurance plans have a relative low yearly maximum payout (less than $3,000 annually). While most medical insurance does take cre of what would otherwise be a catastrophic expense, dental insurance does not. This often means that a patient undergoing a complex treatment plan involving multiple teeth or even a single tooth implant,will be responsible for a large portion of their bill.Those patients requiring a "full mouth restoration" often are responsible for bills of $40,000 or more!

In practice traditional dental plans have been most helpful and rewarded those patients who have not needed extensive dental treatments. They have paid a higher percentage for services such as simple fillings, a single root canal, periodontal procedures, an extraction or semi annual check ups and cleanings. When teeth are lost or need crowning most dental insurance cover a lower percentage of the dental treatment costs and often the yearly maximum is exhausted after only one or two teeth are treated.

The take home message is that prevention large dental problems is the best way for patients to save money. Dental insurance usually will most times not cover more than a modest expenditure (usually less than $3,000) in any given calendar year. Taking good care of your teeth is the best approach. Although modern dentistry can help restore debilitated mouths, often it involves a large out of pocket expense for the patient and dental insurance will not cover the bulk of the costs.

How not to save money on dental care?

I have observed that many patients have cut back on their utilization of dental services in the last several years. Where as in the past, most of my regular patients maintained a regular recall schedule and were seen at least once per year in the office, now a number of my "regulars" have become "irregulars".  They have postponed their 6 month check up and cleaning from one to three years. When they do come in its usually because they are worried about a  dental problem.

While some of these patients end up with a good check up, some do not and it is my impression that often their delay in seeking treatment makes it more likely that they will end up needing a costly dental procedure. I must report that more of my patients are requiring extractions than in the past. This is unfortunate, since aside from these patients loosing a tooth, the cost of a single tooth implant or three unit bridge can be more than their current budget allows. Many are opting for simple acrylic dentures to temporarily replace their missing tooth. While these removable replacements are an affordable option, most patients are unhappy initially with prospect of losing  a tooth and not having it replaced with a "fixed"  replacement.

The purpose of this post is to make the case that seeing your dentist at least once per year for a cleaning and check up is not only a good idea, but may be the most cost effective alternative for most dental patients.

What is the thirty day rule?

In dental school when we were learning how to make dentures we were taught "the thirty day rule". Many patients initially have trouble wearing a new denture, but this rule states that if a patient continues to wear a denture they probably get used to it after 30 days. This rule applies to many things that we experience in  life. Fortunately, people have a tremendous ability to adapt, given enough time.

What are some indications to cement a permanent crown with temporary cement?

I usually choose to cement most crowns initially with permanent rather than temporary cement. When might I choose a temporary cement instead? If  I want to have the patient try it out and see how it works.  Last week, for example, a patient came in with angry looking "overgrown gums" that were making it difficult  to properly seat and cement the crown with permanent cement. If gums are bleeding when a crown is cemented it can cause a compromised result. Also if tissue becomes trapped under the crown when it is cemented this can cause the crown to not fit as it is intended. I cemented my patients crown for one week and then removed it. Now her gums were well adapted, pink and perfect. It was easy to cement her crown with a permenent cement and I was now certain of its fit.

In some other instances if some feature of a crown may still possibly need adjusting later, a temporary cementation can be a good idea. For example, the patient is uncertain whether they like the shade of a crown. Sometimes I am not sure if the bite  is perfect, a temporary cementation may be utilized as well.

Another reason to temporarily cement a crown is to make sure that a tooth will be "happy" with the crown. Many patients complain of sensitivity after a tooth is prepared and temporized. While the great majority are fine after the permanent crown is cemented, a small minority need to have a root canal. If a patients tooth is symptomatic prior to the tooth preparation and remains so afterwards I usually choose to temporarily cement a permanent crown, just in case he or she will need a root canal. Once a crown is permanently cemented a root canal specialist will need to make a hole in it to perform a root canal. Although this is usually not a big problem, sometimes the porcelain adjacent to the hole can chip or break while the endodontist is preparing their access hole. If he is able to remove a temporarily cemented crown he has no need to make an access hole in the patients crown. After the root canal is completed I then cement the crown in with a permanent cement.

A good question to ask is: "Why  not cement all my crowns with temporary cement?" The answer is simple- Some temporarily cemented crowns can be difficult to remove . Using too much force when removing a temproarily cemented crown can cause the a crowns porcelain to crack or can damage the underlying tooth. .  In that event that I am unable to remove a crown easily, with a small  judicious use  of force, my temporary cemention will have to serve as a "final" cementation. Since the vast majority (over 95%) end up without any long term problems, it seems a good idea to routinely cement my patients crowns with permanent cement. It not only saves the patient a visit but it may be the safest alternative as well.

Whats going on in the fish tank?

Our waiting room has always featured a large fish tank. Over the years it has experienced its ups and downs. When I first arrived at my office in 1984 it was an empty terrarium. My partner in the office, Dr. Harold Martin, had tired of cleaning the tank and had left it with some pictures of fish instead of real ones. It was pretty pathetic!.

During an office redecoration I replaced the old fish tank with a new fresh water one. It was a  really nice addition, but required a fair amount of attention and I too tired of caring for it. Eventually my assistant Larysa ended up taking over and cared for the tank in her limited free time.  We were down to one lonely fish when my neighbor, Dr. Buckner came over to the office and said that he loved fish and always wished that he had a tank like mine. I jokingly said he could be in charge if he liked. Surprisingly. he said that he would love to take it over and make it into a salt water aquarium.

In the last two years he and Bill (his aquarium expert) have turned the tank into a veritable Shangra La for sea animals. The tank features a variety of invertebrates and an assortment of pretty saltwater fish. Lately Bill has been bringing over new specimens almost every other day and the tank looks great. At this point the tank is mesmerizing!

 Isn't Life grand?

Why are you not supposed to eat after having a filling?

When silver fillings are placed they continue to harden for the next twenty four hours. Dentists often ask patients to refrain for eating for 45 minutes in order to allow time for the filling to be hard enough to withstand the pressures involved with eating.

Even patients who have had composite filling placed would be wise to not eat for a short time afterwards so that their numbness can wear off. This is especially true for lower fillings, since the mandibular block anesthesia often used numbs both the tongue and lips. Patients who eat before sensation returns risk accidentally chewing on their tongue or lip.

Do I really need an examination each time I have a cleaning?

In an ideal world the answer is yes, but in the real world when we place patients on a 3 month recall , we do not insist that they have a dentist examination for each cleaning. Dental insurance usually only allows two exams per year and often only covers two cleanings per year as well. Often, to encourage our patients who need more frequent cleanings, we do not insist that they have more than two examinations each year. If the hygienist does see something out of the ordinary she will suggest that I come in to examine the problem, but most times my examination is not required.

I certainly encourage people to have a dental examination at least once per year, since often dental problems do not hurt initially. If patients wait to see the dentist until they are in pain, they may have problems that are harder to fix and may make a root canal or the loss of a tooth  more likely

How do I keep my teeth from yellowing?

It is natural for teeth to become more yellow as we age. Some of the yellow hue comes from the deposition of secondary dentin that can occur over time inside the tooth. Some of the yellow can come from the absorption of colors from the food, beverages and from cigarette smoke( if we smoke).

The best way to minimize this yellowing is to use a good electric toothbrush and have our teeth cleaned regularly. For those who seek to reverse this process I would advise them  to consider having custom bleaching trays fabricated at your dentist. These thin trays can be worn at night or day to apply a carbamide peroxide formula to the teeth.  This technique is an  effective and safe way to brighten and whiten teeth.

Why did you start blogging?

I originally started this blog in 2005 after speaking with one of my patients who worked for iVillage. I asked him if they would be interested in me starting a monthly dental column. He asked "Can you write?". I confidently responded that of course I could and he suggested that I should start a blog on Blogger. I must confess that I knew nothing about blogging or Blogger, but he asked me to write several sample posts so that he could have someone at iVillage look at them. I started the blog and wrote several "sample posts".

He left Ivillage soon after and I never started a monthly column there, but after I put up a website for my dental practice I thought that my blog would complement the content on the site nicely. I started blogging slowly and I still at it.

Sometimes it is a challenge to come up with topics to write about (including today!) but I try a write at least one post every week, either between patient appointments or on the weekend. Most of the people who read my posts are sent here by Google searches and in March the blog received over 16,000 hits.

The posts are mostly answers to  questions from my own patients and most  do not require a great deal of research on my part. If the blog is helpful to others seeking answers to dental questions, I am happy to help.

Why are my crowns not fitting?

First let me say that most of my crowns end up fitting nicely, but most do not drop into the moth without the need for any adjustment. I am writing this post for primarily for dentists who are having problems with the fit of their gold or porcelain fused to  crowns and are looking for help with this problem.

There are a number of reasons for crowns not to fit and these include over extensions, poor preparation, over tight contacts, poor impressions and poor laboratory work are just a few reasons, but let's assume for the moment that you are  reasonably happy with your laboratory , feel confident with your preparation and impressions and your crown is still not fitting.

Since I ditch my own dies over extension is not usually a problem and I use small dental laboratories where the same technicians perform my work and usually my preparations are carefully done. Even so, sometimes crowns do not fit on my intitial try in. I also almost always use a bevel or a finishing line with at least a .5mm clearly readable width. When one of my crowns doesn't fit there are usually several possible common reasons and I have a standard way of trouble shooting my crowns.


First I check for an over tight contact. Improperly tight contacts can keep crowns from seating. In order to check a contact, after I have initially seated a crown,  I use unwaxed dental floss and see if it can be moved without a great deal of effort through both contacts. If it breaks or shreds I usually assume the contacts need adjusting. Commonly I paint Accufilm marking liquid {Parkell}(Occlude spray can also be used) on the contact areas of the crown and seat it again and look for where the ink gets removed.  This is usually the spot that needs adjustment. I do this repeatedly and make small adjustments until my crown can be flossed easily with unwaxed floss. I also find that a product called Contact Eaze is helpful as well. Its a tiny extremely fine short lightening strip mounted on a plastic handle that is easily used to adjust contacts while a crown is seated on its pindexed model.

After I determine if my contacts are OK I routinely use GC fit checker to check the internal fit of my castings. To do this I mix a small amount on a paper pad with a plastic instrument , apply it in a thin coat to the walls of the dried crown and then seat it. After 90 seconds I remove the crown and examine the inside carefully. If I can't see an extremely thin coat at the margin I look carefully for any metal poking through the silicone . Usually these tiny metal "drag" marks are due to tiny undercuts on the crown preparation that have not been blocked out by the lab technician. On my crowns I commonly find these on the proximal surfaces of my preparations near the occlusal aspect. I relieve these tiny spots with a small latch type round bur run at low speed and then sandblast the area. (Another approach that I sometimes use  is to paint the inside of the casting with some Accufilm marking liquid and re-seat the crown. The Accufilm can adhere to the tooth and show me where the tiny under cuts are located). I do the fit checking repeatedly until I am happy with the fit of each casting. I know that I have a well fitting casting when the bevel area looks like it has an extremely thin even coat of fit checker on it and most times the film thickness on the bevel is thin enough that the grey from the casting is apparent through the set fit checker.

Another thing that the fit checker can help detect is tissue impingement around the preparation that may not allow a crown to fully seat. In that case the casting may have a thick blob of set white fit checker at one part of the margin. It is always a good idea to make sure that the margins are cleaned of tissue before re-seating the crown with the next round of fit checker . Over extensions also may become apparent with the fit checker. These are areas at the margin of a casting that have no fit checker. If I find this denuded area repeatedly on a margin it either indicates an over extension or a binding spot at the margin that needs slight relief.

The number of times that I apply fit checker could be as little as once to as many as ten times. If I have to use many fit checker applications, I am not a happy camper. Most times after this process I am happy with the fit and cement in my patients crown, but if I am not, I will take a new impression and ask my laboratory to redo my crown. If I find that my crowns are needing too much adjustment in a given month, I definitely will have a "pow-wow" my lab. In the last year or so I have started dividing my work between two high quality dental labs. Both are aware that I split my work between them and it seems to have the overall effect of improving the quality of their restorations.

What keeps teeth from breaking when we chew?

Given the forces that are jaw muscles are able to generate it seems miraculous that we do not break our own teeth When chewing. How do we protect our teeth from our teeth from biting down hard and accidentally breaking our own teeth. The answer goes way back to the time of the dinosaurs!. Teeth were a necessary adaption for dinosaurs to become carnivores and they probably developed a neurological feed back mechanism to inhibit their teeth from coming in contact with the full force generated by their jaw muscles. When we use our teeth to crack something hard we hardly ever let our teeth meet with anything but light force. If we didn't we would surely break them.

An article in the New York Times yesterday "The Marvels in Your Mouth" did a good job of explaining how we able to keep from harming our own teeth during chewing. I guess we owe the dinosaurs a debt of gratitude.

Whats new in the office this year?

Last November we expanded our management software to include the capability of sending out confirmation email and text messages. After several short training sessions, we started using the system this year.  The software prompts the person receiving the  email or  text to press one to confirm their appointment and if they do so, their appointment is confirmed in our office computer schedule. My office manager Ida still spends time confirming patients who either haven't responded or have not yet given us their cell number or email address.

The module that we purchased, Dentrix eServices,  also allows us to automatically send out  recall reminder postcards as well  as eClaims. We are still learning the ins and outs of the program, but so far we seem to be saving administrative time and we have had positive feedback from the majority of our patients.

Are fillings only placed because of decay?

Most fillings are done because the dentist suspects that decay is present, but sometimes dentists place a filling to prevent future decay. One example of when this is true is when a dentist replaces a broken or defective filling. Often dentist will replace filling when it is apparent that they no longer seal the tooth properly and future decay may occur if the filling is not replaced. Another reason that I can place filling is to seal a defect in the enamel that either may worsen due to erosion or due the likelihood of future decay. Examples would be abstractions at the neck of teeth and also very deep fissure in teeth that are collecting debris. In both of these instance I advocate placing conservative (minimally invasive) fillings in order to prevent future potential problems.

What should I do about a toothache?

Although there are many causes for "toothaches", the correct procedure is to call your dentist. If you do not have one call a friends dentist. If its after hours leave a message for the office to call when they get the message! Ok, but what to do until  they call you back? The first thing to try is to take a pain killer such as Ibuprofen (Advil or Motrin) or Aspirin. Both of these medications are not only good at cutting down inflammation but also provide pain relief for mild and moderate pain. Both are excellent to be used as first line medications for tooth pain.Do not take a stronger narcotic medication without trying one of these two. The sole exception would be for someone who  has a bleeding  problem or an allergy that can be caused by either of these drugs. If you do have a problem with either of these non-steroidal analgesics, then acetaminophen is often recommended as an alternative .

It is not advisable to place aspirin inside the mouth in an attempt to alleviate the pain. Some patients try and holding this against the tooth in an attempt to stop the pain, but the medicines can cause burns in the gingiva. Rinsing frequently with warm saline solution can help in the event that a patient has a swelling in the gum.  It is not advisable to place a hot compress on the outside of the face, since this can draw an infection toward the skin of the face.

Sometimes patients experience toothaches immediately after eating. Usually these people have a tooth or teeth with deep caries and eating can cause the teeth to throb. For these patients I advise not letting food come in  contact with the painful tooth(teeth) since it can cause a worsening of the tooth ache. Often teeth with deep cavities and vital pulps will calm down on their own if left alone for a short period of time(an hour).

If you are experiencing an "after office hours" tooth ache and can not reach your dentist, a trip to the hospital emergency room is an option, since many emergency rooms have oral surgeons on call (especially teaching hospitals that have dental residency programs)