Why do dentists vary so much in their treatment plans and fees?

Although dentistry can be treated like a commodity just like any other, it is an art and not a science. Dentists often discover techniques and treatments that "work well in their hands" and tend to recommend them to their patients. Many dentists do things differently and invariably some offer better results than others. Often in dentistry as in life, it not what you do that’s important, it’s how you do it! For example, an excellent filling can be better for a patient than a poorly fitted crown.

Fees are of intense interest to many people shopping for a dentist and often patients seem to be shopping for affordable dentistry. This is all well and good, but usually it is wise when seeking ‘bids’ to stay away from the low bidder (unless you’re our government?) Of course high fees do not guarantee good work, but as one of my wise dental assistants once pointed out "You can’t get to heaven without dying”. Similarly where dentistry is concerned, good work often takes time and usually has a fee that properly reimburses the dentist for it.

This last part is some advice for those patients with PPO dental insurance. If you are happy with your dentist and have achieved good results over the years, but are unhappy that he doesn't participate with your dental insurance plan, you might be wise to stay with him or her. It can be difficult to judge the quality of a dentist's work solely based on an interview or relying on online dental reviews. Of course there are many fine dentists participating with dental insurance plans, but switching dentists when you are happy may not be the wisest choice. This is especially true if you really can afford his services, but are hoping to save a little money by switching to a participating office.

Crown instead of core in composite after root canal?

This is a question that I was just asked by questioner on allexperts.com. I thought it was a good one, so I am posting a longer version of the answer here as well. It is a question that many patients have after a root canal. Why can't I have a filling instead of a crown? I usually have a separate answer for anterior and posterior teeth.

For anterior teeth, after an endodontic procedure I often recommend just filling the endodonic access hole. These teeth often experience a considerable lateral force component and preparing them extensively for a crown can weaken their ability to withstand these forces. If of course, they are missing too much tooth structure I will crown them, but otherwise I will often fill them. If they need too due to darkening of the tooth, I will often recommend a porcelain veneer. This restoration requires less tooth preparation than a full crown.

For posterior teeth (Molars and premolars) I almost always recommend a protective crown or onlay restoration. Not only do these teeth experience a greater percentage of vertical vs horizontal force loading, but they also are under greater stress due to their position in the jaw. The further posterior a tooth is in the dental arch, the greater the occlusal force it experiences. In my opinion they will more likely fracture than anterior teeth without cuspal protection. Both crowns and onlays can offer far better protection than a simple bonded filling or core will.

Why is dental floss probably the best investment you could ever make?

Ok, maybe this is a little overstated, since purchasing Google stock at the IPO might yield a better rate of return, but floss purchased and used properly at an early age will yield high dividends in the future. If a twelve year old starts using floss correctly on a daily basis, there is a good chance he or she will never develop proximal caries. Assuming that he or she sticks to a recommended twice yearly cleaning and check up, periodontal disease is not likely to become a problem.

Over the course of a lifetime, not having to repair, extract and replace teeth may save enough money to buy a very expensive car or two (depending on how much dental work they would have required). In this economic climate, saving money is a hot topic, and I am making a pitch for us all to save money by taking better care of our teeth.

If you are like most people you probably haven't always been a perfect flosser and probably haven't always had your teeth cleaned on schedule, but it is never too late to do better. Why not make a belated New Years Resolution? Why not resolve to floss every day and of course please schedule a recall appointment when my secretary calls to remind you!

Can a tooth still have feeling after a root canal is completed?

Root canal procedures remove the pulp from a tooth. Even when some tissue is left behind it is not living tissue. Endodontically treated teeth do not have the ability to feel cold sensitivity unless vital pulp tissue remains in an untreated root and this rarely is the case.

If your endodontically treated tooth seems to be sensitive to cold, the most likely cause is an adjacent tooth. A visit to the dentist where he performs an ice challenge will usually demonstrate which tooth is experiencing sensitivity.

That being said, teeth with endodontics still can feel pain due to the presence the periodontal ligament. If the tooth displays either periapical inflammation or infection it can be sensitive to pressure, chewing or percussion. Failing root canals can present as 'toothaches' as well. Cracks in endodontically treated teeth similarly can cause pain in the surrounding periodontal ligaments.

Can a denture look natural?

Full dentures can provide a patient with a natural cosmetic result, although sometimes it requires a team effort with a dental laboratory to achieve the optimum result. The technician setting up the denture doesn't have a patient's lips in front of him when he is creating his denture set up. Often denture teeth are placed too far out off the alveolar ridge so that when the denture is worn the teeth appear too prominent. If necessary the dentist may have to ask the technician to grind the backs of the teeth in order to allow them to be set up closer to the patient's alveolar ridge.

It is up to the dentist to try a denture in while the teeth are set in wax in order to verify that the setup is pleasing and that the teeth are correctly positioned. Also teeth should be arranged with some variations in orientation and position and should not be over aligned since this can provide an artificial look. Natural teeth have some variations in their alignment and this must be evident in a denture set up in order for it to look natural. It doesn't take much variation to be esthetic, but there should be some.

This concept is true for all cosmetic restorations,porcelain veneers included. Too much symmetry can lead to a static and unflattering presentation that can create a look that might be incorrectly termed "the denture look" where every tooth is exactly and ideally placed so that the overall result is too perfect and looks artificial.

Can a dentist alter the crowns or bridges that a dental laboratory provides?

Absolutely. Often dental restorations provided by a dental laboratory require minor modifications in order to fit or look right. When inserting a crown or bridge I do a number of checks, prior to insertion. I check the contact points, the internal fit, the occlusion(bite), and may do minor alterations of the shape to improve a crown or bridges esthetics. Often the modified crown or bridge need not go back to the lab, but is then polished "chair side" and inserted either temporarily or permanently.

These minor modification can make the difference between a potential failure and a succesful dental restoration and I feel a dentist should routinely check laboratory restorations for fit,function and esthetics prior to permanent insertion. As beautiful as crowns and bridges can look on their models, they must fit and look good in the mouth as well.

How do you make root form implant temporaries?

There are a number of ways. The photo above was made by taking a fixture level open tray impression and having the laboratory fabricate a temporary bridge with root contours.

Usually when I am temporizing a single implant in the "esthetic zone"(From premolar-premolar) I use a prefab Ion crown that I attach to an implant part specially designed for a screw retained temporary. I customize the root portion using free hand composite material. It works nicely, but takes some chair time to fabricate properly.