Are Dentists "Recession proof"

I am asked this question during every economic downturn. Most patients assume that dentistry is recession proof. I have been in practice for over 27 years and bad economic times effect dental practices.

Dentists are not recession proof. During periods of economic downturn, patients are less likely to do elective cosmetic treatments, schedule dental check-ups, and I have noticed that during every recession a increasing number of patients choose to 'pack their bags' and move to some other location where they hope the 'grass is greener' or at least cheaper than NYC.

During times of anxiety, caused by a bad economy and other factors it seems that our telephone doesn't ring as often. Could it be that patients worried about finances, often do not tend to take prevention seriously? Conserving money may take presidence over dental cleanings and check-ups. I have noticed that this pattern contiues for months during a recession.

At some later point, It seems that I start getting an increasing number of patients calling who have toothaches. Often, I am required to perform root canal treatment or extractions for them. The actual cost of treatment for these patients, is usually higher than if they had come in for their twice yearly check-up and cleaning and maybe had a simple filling.

Crown Lengthening or Implant?

Teeth have crown lengthening when a dentist either decides that he can not place a margin on a tooth for a crown without getting too close the the patients supporting bone(closer than 1.5 mm) or the tooth structure remaining is insufficiently strong to hold a crown predictably.

In the event that 'insufficient tooth structure' remains, removing bone aroung a tooth can expose new tooth for a future crown to grab onto.

Crown lengthening can be a good thing providing only a small amount of supporting bone needs to be removed and the final result is cosmetically appealing.

Crown lengthening is a bad idea if it involves removing supporting bone from adjacent teeth that might compromise their longtime prognosis, or if the resulting gingival position is unesthetic. In either of these two situations implants usually are a better alternative

My root canal has failed what should I do?

When a root canal fails, the tooth becomes infected and develops an area of infection at the end of the root. This infection can get worse with time and eventually cause the tooth to be lost. It can affect adjacent teeth and even can spread to other parts of the body.

There are three options for dealing with failing root canals.The best is re treatment, which involves removing the root canal filling, re instrumenting the canal and irrigating with bleach which disinfect the canal. The canal is sealed and closed. Assuming that the tooth can be adequately shaped and sealed this approach works well a high percentage of the time (probably better than 90% of the time).

Sometimes a tooth is difficult to retreat adequately, for example an instrument was broken and blocking the canal, or the tooth was restored with a post and a crown. In this case Apicoectomy is possibility. In this procedure, the a small flap is made in the gum and the end of the root is visualized through the access that has surgically created. A small part of the end of the root may be removed and a 'retrograde' seal placed into the new end of the root.

Apicoectomy(Apical Surgery) is an accepted treatment for failing root canals, but it's success rate is definitely lower than conventional, non surgical re treatments. If I have a choice of which treatment to choose for a patient I often advise a conventional re treatment, even if it requires the removal of a post and a crown, prior to re treatment.

The third option is extraction. This is a good option if a re treatment has failed, or if the tooth involved does not have sufficient tooth structure to predictably restore. If a tooth is restored, and later sustains a vertical fracture, further bone loss can result. Some badly decayed or broken down teeth are more likely to sustain vertical fractures when restored. Implants require adequate bone being present and sometimes it is best to remove a tooth and place an implant while there is still enough bone at the site.

Do you do same day denture repairs?

Often we are able to fixed cracked dentures in as little a day(or less). We work with a Dental laboraory in the building and most days we are able to accomodate. If you do have a cracked denture and desire a same day denture repair, please call for an appointment.

Do you make patients lie all the way back to have dental work?

This question was asked of me by a very nice woman who was sitting across from me at a wedding reception just this weekend. It turns out that she had a unpleasant experience at the dentist, who apparently was working on an upper tooth and had the dental chair all the way back. She felt like she almost'drowned' from all the water she swallowed.

The answer is that I like to put my patients chair back when I am working on upper teeth, but it is not unsual for some of my patients, especially the elerly to ask that I not put the chair back all the way.

I try to accomodate them by placing the chair just slightly further back than 45 degrees and that seems to work better for those patients who feel they can't be put back 'all the way'. Sometimes the procedures take longer for me to perform, but I do try and make patients confortable if possible.

My post broke off inside my tooth. What can be done?

The answer is it depends. Although every situation is different, some posts that appear at first impossible to remove, can be removed. Yesterday a patient of mine came in who had broken a 'flexipost' off inside her lateral incisor root. I had previously sent a copy of the X-ray of the tooth showing the broken post to my favorite root canal specialist. I spoke with him on the phone and he felt that the tooth should be extracted an implant put in.


When I explained this to my patient she was extremely upset about losing her tooth and the expense of the implant that she would need. I studied the X-ray carefully and decided that I just might be able to remove the post. If I failed I could always have the root extracted.

From viewing the X-ray I could see that only two mm of solid threaded post remained. The remaining threaded post had been designed with a split down the middle in the threads,so that it would not put undo pressure on the root.

I correctly guessed that by drilling and removing two mm of the post I would be able to access the split portion of the threaded post. Using 4.5 magnification, a tiny drill and bright illumination, I was able to remove the two mm of solid post. I was able to expose the split portion of the flexipost. I inserted my ultrasonic cavitron tip into this area and carefully loosened the remainder of the post.

After the post was removed I made a new bonded post with a more flexible fiber post and built up the core with composite material. My very relieved patient left the office with a new temporary crown in place.

I guess it was a 'good day for dentistry!"

Why do porcelain veneers pop off?

One reason is occlusion. If when a patient moves his jaw and it causes the incisal edge of a veneer to hit an opposing tooth with too pressure, sheer force is experienced by the veneer and the bonding cement holding it. Over time this can cause either the veneer to break or for the veneer to separate from the underlying tooth.

Another factor can be lack of underlying enamel. When preparing veneer, it is not uncommon for the dentist to remove all of the enamel from some spots on the underlying tooth and in those spots dentin is exposed. Unlike enamel, dentin doesn't bond well to the veneer. If too much dentin is exposed during preparation, then a veneer is more prone to pop off.

It is also possible for poor bonding technique or poorly fitting veneer to be additional possible causes of veneer failures. Excess moisture contamination and poor acid etching of enamel can be examples of poor bonding technique.

Poorly fitting veneers are often held to the teeth by a thick layer of bonding resin which is weaker than a thin layer would be. I suspect that veneers that do not fit intimately and are held in by a thick layer are more likely to fail.

I have intermitant pain on chewing. How do you figure out which tooth is bothering me?

When a patient has intermittent pain on chewing it usually involves some detective work. Often nothing unusual shows on an X-ray. Quite often the pain originates from a crack in a particular tooth.

A visual inspection of the quadrant where the patient has pain is the first step. I look for a tooth with a large silver filling or a tooth with visible cracks in it.

I tap all the teeth in the quadrant gently with the back end of a dental mirror to see if one of the teeth feels 'different' then the others. Often, but not always, the offending tooth is slightly achy when tapped.

My last tool is the Q-tip test. This test is designed to simulate chewing food. I ask the patient to bite on the cotton part of the Q-tip and move it around until they experience the pain. When they feel the pain I pull their cheek back and can observe which tooth is bothering them. If they do have 'cracked tooth syndrome', this test determines which tooth is most likely cracked.