CERAMIC CROWNS ON SECOND MOLARS

What is this a photo of?

Something I see far too often lately! This is a broken ceramic crown on a patient’s lower left second molar. It fractured in two, and the half on the tongue side of the molar is still hanging on. The patient thinks she had the crown placed about eight years ago.

Why did this happen?
The human jaw is a lever system configured like a nutcracker. Your muscles can generate about four times the force in the second molar area than can be generated on your incisor teeth in front. Some patients grind and clench their teeth. It is no coincidence that most fractures of teeth occur on second molars.

The emphasis on esthetics nowadays is so powerful that some patients think I am crazy when I tell them second molars are not the place for ceramic crowns. They either break like this one did, or repeatedly come uncemented. If you have to drill a hole through a ceramic crown to do a root canal, good luck to you. It is a tough job. Can you imagine drilling a hole through a porcelain dinner plate?

Computer-milled zirconia crowns were invented almost twenty years ago. Like most new products, their advantages were exaggerated. They were tougher than traditional porcelain crowns with a metal substructure, it is true. But they were NOT unbreakable, as was claimed. It was advertised that they could be made as thin as half a millimeter, like metal crowns, and still resist fracture. That turned out to be a lie.

Two other disadvantages of milled zirconia crowns: they are so inert that cement often does not bond well to them, and they are so hard that they often wear the natural tooth above or below them.

When I tell patients these facts, the response is often, “Why didn’t my former dentist give me other options?”

The reason is that computer-milled zirconia crowns are currently the cheapest ones available from dental labs. Low cost drives their popularity with dentists and patients alike. But how much does a patient save if a ceramic crown breaks in a few years and has to be replaced at additional expense?

What are the alternatives to ceramic crowns?
They may not be white, but I have never in my career seen a cast metal crown break in two. For nearly a century, metal crowns, particularly ones made of gold alloys, were seen as the standard of care for posterior teeth. They are the crowns dentists themselves most often have in their own mouths!

Nowadays gold is considerably more expensive, but we often make crowns out of more economical alloys like silver-palladium and chrome-cobalt alloys, and they are just as durable.

In the old days when gold crowns were the norm, teeth were cut down far more conservatively, and as a result, fewer teeth needed root canals. Gold crowns occasionally wore through on the chewing surface, but that could be repaired. A fractured ceramic crown cannot be salvaged!

As I tell patients every day, durability needs to be factored into patient choices in dental treatment. Especially in high force areas like the second molar region, it is hard to beat cast metal crowns. Sometimes the tried-and-true methods of doing things are still the best way!

Kim Henry, DMD
December 5, 2023

Medicare to the Rescue for Senior Dental Care?

Senior citizens are excited! Most lose their dental benefits coverage when they retire from their job. After that they are on their own paying out of pocket for necessary dental treatment. Quite frankly, this can cost quite a bit of disposable income for retirees if big-ticket services like crowns or implants are needed.

Now some politicians are promising that dental as well as vision benefits will be added to Medicare. It is not clear how these new benefits will be paid or financed. It seems improbable that government could retroactively increase Medicare deductions on a lifetime of earnings. Barring that, I guess politicians will promise that rich people will be taxed to pay for the new benefits.

Let us take a step back and look at medical reimbursements under Medicare. Despite inflation, they have not been increased in years. Congress actually has to take periodic action to keep Medicare fees from automatically being reduced! Not many GPs or internists want new Medicare patients because government fees are set so low that treating seniors is a money-losing proposition. The Greenspan commission concluded many years ago that Medicare would run out of money before Social Security does, and its predictions are now coming true.

Did you know that even if physicians opt out of participating in Medicare, they can only charge 10% more than the government-fixed low Medicare fee? Medicare is unlike every other private medical insurance policy in this regard. Physicians receive very little for treating Medicare patients. At the last visit, my personal physician said he would only receive $18.34 for my routine office visit. (That is why I usually give him a generous cash tip to continue treating me.)

Do you really think that any Medical dental benefits plan would pay a reasonable amount to dentists for performing treatment, when Medicare is already tottering on insolvency? No, any Medicare dental plan will pay low fees comparable to the lousy medical fees currently paid to physicians.

What kind of dentists will sign up to treat patients on Medicare dental plans?

It will certainly be the usual suspects – high volume corporate dental clinics which play fast and loose with billing procedures. In other words, crooks. Shady billing is almost a necessity to turn a profit treating Medicare patients in medical offices, and the same will be true for dental offices. The only providers likely to work in such clinics will be desperate, inexperienced recent dental school grads.

Any new benefit offered by the government to voters is likely to be very high in promises, and very low in quality. This is especially true with the enormous budget deficits incurred after the COVID-19 pandemic.  As enticing as Medicare dental benefits may sound, patients will likely be very disappointed with the final outcome. Dentistry is a very high overhead profession, and there is no way legislators are going to change that by signing an expansion of Medicare into law. In fact, government regulations are to a large part responsible for the present high cost of dental care.

Kim Henry DMD

October 21^st, 2021

CORPORATE ORTHODONTIC CARE- A BAD MOVE!

Parents of a 13-year-old child came in to have me review the appropriateness of their son’s orthodontic treatment. The father had wanted to bring their son to me for treatment originally, but the mother saw an advertisement for a chain of orthodontic clinics, promising substantial savings. The mother’s wish prevailed, and the child was 1 year into orthodontic treatment at this clinic with little progress.

I examined the boy. His was not a particularly difficult orthodontic case. I could have treated it in a little over a year and a half. But the corporate clinic had only fabricated some kind of removable expanders the child could not tolerate wearing regularly, and nothing much had been accomplished in the year of treatment.

It was hard to give the parents my conclusion. “I hate to tell you, but if I were to treat this case as it should have been when you started, it will cost you just under $4000 to complete. I guess your only consolation will be you didn’t spend much on the treatment that did not work.”

The mother looked visibly disturbed. She said, “Oh no. We have already paid $4000 for the treatment that has been done so far!” This woman had brought her son to a corporate orthodontic clinic thinking she would save money, and they totally wasted more money than what I would have charged to do the case correctly!

Not to brag, but I have been doing complete bracketed orthodontic cases since 1987. I know what I am doing. If patients cooperate, we get cases done quickly. I know a hard case when I see one, and have the sense to refer it to a select few orthodontists I know the ones who are super-competent.

Patients heed my recommendations about orthodontists very seldom. They listen to what I say. Then they go home and ask their friends and neighbors where to go, or they see some silly TV advertisement for a corporate orthodontic clinic, and go there.  Many times, their case will never be completed correctly, if it is ever completed at all!

One of my adult patients asked me about straightening his teeth. I could see his case would be very difficult, with a high probability of needing jaw surgery to complete. I made a strong recommendation of one or two excellent orthodontists for such exacting treatment. The patient ignored me, and went to a corporate clinic. Fortunately, he later called telling me that they planned to do his initial exam and put the brackets on the same day. This was preposterous!

Any sane dentist would do an exam, take records, then do analyses and feasibility studies to work up such a difficult case as his. I spend at least 2 hours of analysis to work up an easy orthodontic case! Timing in orthodontics is often critical as well. Many cases, if started too early, will drag on for too long. These days, I often post photos of patients’ mouths online (omitting patient name, of course) and seek other orthodontists’ opinions about how the case should be treated. It would be ridiculous to put brackets and archwires on a patient the same day as the exam!

After being warned of the foolhardiness of proceeding, this patient changed his mind, took my advice, and saw a competent independent orthodontist. This is not always the outcome! Unfortunately, too often corporate orthodontists succeed in slapping on brackets and archwires to “lock in” the patient’s treatment at that clinic. Only afterwards do they try to figure out how to treat the case!

All good orthodontists forward a copy of their findings and treatment plan for a patient case to the treating general dentist. I virtually never receive these from corporate clinics, leading me to question whether there is even any logical treatment plan. I have received requests to extract teeth from corporate orthodontic clinics, then had to demand a rationale for the extrac­tions before I proceeded. I guess these orthodontists are under such pressures to perform, they allow no time for communication with the patient’s dentist!

Corporate ownership of orthodontic practices began in the early 1990s, as a result of the oversupply of orthodontists. Private equity investors thought they could use the same sales and business techniques to straighten teeth as they used dealing with auto repair and vacu­um cleaners. Health care is different, because all humans are all unique. No two orthodontic cases are exactly alike. There are even some orthodontic cases that should not be attempted. It is important that treating orthodontists not be subject to the will and profit incentive of non-dentist investors to treat the maximum number of cases without regard to appropriate timing or case difficulty or without sufficient diagnostic preparation.

Not every case I have seen from corporate orthodontic clinics has been done incompetently, but there are enough substandard case completions to be worrisome. One thing for sure: I don’t see any patient cost savings from corporate clinics, despite what is claimed in their glitzy advertisements.

As with every other service, I have personally found that the highest customer satisfaction is given by professionals who own their own business. It is true for general dentistry, and it is true for orthodontics as well. Please be skeptical about TV, radio, or print ads telling you to patronize any particular chain of orthodontic clinics. If you have any doubt before treatment, don’t hesitate to ask me about any particular orthodontic group you are thinking of using.

Kim Henry

January 24, 2015

Please Support Mom & Pop Pharmacies!

The other day a surgical patient needed a prescription filled for an antibiotic and pain reliever we had given her. She went to a big-box chain pharmacy to get it filled. Three hours later, a young voice called us saying the prescription could not be filled without an “attending physician’s” name. Missy repeatedly told the employee that ours was a dental office and all the necessary information was printed on the prescription. I was busy and could not take the call at the time. When we tried to call back, we were placed on hold for 30 minutes, and never could talk to anyone in the pharmacy.

The patient never was able to get the drugs she badly needed that evening. The store manager called us the next day to say that a young, inexperienced pharmacist was on duty that night, and did not know what she was doing.

I wish I could say that occurrences like that were a rarity, but such a fiasco happens nearly every week. Patients don’t realize that I can rarely speak to the pharmacists in big-box stores. They are just too busy and understaffed. I usually can only leave recorded messages on their voice mail systems. Eventually staff listens to most messages and fills the prescriptions, but a good part of the time they never get around to it. Then the patients often blame me, thinking I forgot to phone in the prescription.

Often times big-box stores don’t stock a variety of drugs, or enough of them. They often run out. Then they lie to patients and said I prescribed a rarely-used medication.

Patients always want to save money, but what is your time really worth? Is three hours of waiting worth saving $4?

The difference between dealing with big-box pharmacies and Mom & Pop drug stores is like night and day. I can call and talk to a pharmacist almost immediately. They give me suggestions for drugs that might be alternatives. They cut me slack and let me phone in scheduled drugs, and wait for the written prescription by mail. They work hard for patients’ business, and truly put patients’ interests first. Often the difference in drug costs between big-box and independent pharmacies is little if anything.

There aren’t many Mom & Pop pharmacies left, but they deserve your business. Chapman’s Drugstore in Hapeville has been in business for over 80 years and is only two blocks from my office. You seldom wait more than five minutes for a prescription! Christian’s Pharmacy in Forest Park is owned by one of my patients, and can even compound custom prescriptions for you. Moye’s Pharmacy gives speedy and efficient service to my patients in the McDonough area.

Corporate ownership has been nothing but bad for the dental profession, and I am not sure that it has been any less damaging to pharmacies. Please consider using your helpful independently owned local pharmacy next time you need a prescription filled. You will also support a valuable small business in your community!

Paying for Dental Care with a Health Savings Account

Do you perhaps fit in one of the following groups?

• *Employer offers no dental benefit plan.
• *Employer offers dental benefit plan but does not subsidize premium, so it is no deal.
• *Employer dental benefit plan excludes treatment you need, like implants.
• *Dental plan that employer offers is a crumby PPO or DMO that excludes using good dentists not on the insurance list.
• *You have a very healthy mouth, and virtually never need any treatment except regular cleanings, exams, and occasional x-rays, so dental coverage does not make economic sense.
• *You are a self-employed individual without any form of dental coverage.

As expensive as dental care is, it really hurts to pay for it with after-tax income. Patients know that my #1 recommendation for funding dental care is through a FLEX benefit plan. It gives you complete freedom to pick dentists, and save all taxes on the money you put into it. You even avoid Social Security and Medicare taxes on salary you defer to the account!

Trouble is, as good as FLEX benefit plans are, not all employers offer them. And self-employed individuals cannot use them, unless they have a C-corporation.

What is a patient to do?

A good alternative is to use a Health Savings Account, which is much more efficient than buying dental insurance. Unlike when using a FLEX benefit plan, you will not avoid Social Security and Medicare taxes. But it will save some Federal and State income tax. How would you go about getting a Health Savings Account (HSA) open?

1. You must select a high-deductible, HSA-eligible medical coverage. More and more employers are offering this option. Typically the deductible must be at least $1200.
2. Fund the account to an EXCESS of what you need to pay for your medical deductible and copayments. For instance, if your typical out-of-pocket yearly medical expenses are $1500, contribute that PLUS however much per year you believe you will spend on family dental expenses. Ordinarily one would think to only contribute as much as a dental plan premium would cost monthly. But remember that any dental plan includes substantial out-of-pocket deductibles and copayments. So a starter would be to contribute 150% of the cost of premiums to a good dental plan.
3. The best place I have found to open a Health Savings Account is Delta Community Credit Union, because they have no fees and pay a good rate of interest. Perhaps some other credit unions have as good a deal.
4. You will get an HSA checkbook and/or debit card to pay your dentist with. He will love you, as you save him so many insurance hassles! And no insurance company will prevent you from having any dentistry you feel you want and need.

Individual dental benefit plans have always been a waste of money. We are finding that more employer-based dental plans are either poorly written, not a good deal, or both. Skipping the middlemen of dental plan underwriters can save you money and give you unlimited freedom of choice!

Feel free to e-mail me at KimHenryDMD@mindspring.com if you have any questions about implementing HSA dental funding.