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

TWO PATIENTS LOSE MONEY TRYING TO SAVE MONEY

It is hard to resist a “deal” that will save you a sizeable amount of money, isn’t it? Nobody wants to pay more than they should for something. So many times, we see patients leave our practice for “great deals” elsewhere, and they end up paying a hefty price for it. Here are two recent examples that I encountered in one week, plus one disaster yet to happen. Naturally, I am not using real patient names in the stories.

Lucia

Lucia had lived a good part of her life in Peru. There are some good dentists in Peru, but there are also plenty of bad ones, and even assistants practicing as dentists with forged degrees and licenses. Lucia’s Peruvian root canals were poorly done. We were able to redo some of them, but she lost one tooth. Two long lower fixed bridges connected to wisdom teeth in the back had also been done in Peru. Even if the bridges weren’t overly long this would not have been a good idea. As usually happens, the porcelain was cracking off, and the bridges came loose from the wisdom teeth, causing decay underneath.

I told Lucia the span was too great for fixed bridges, and she either had to resort to a removable partial or implants. She did not want anything removable, and believed she could not afford implants.

Lucia’s husband found what he thought was a good dentist in Mexico that would fix the problem at lower cost. Maria returned to my office with two new fixed bridges attached to the wisdom teeth- just like the ones that failed before. The porcelain is already cracking. The bridges were excessively contoured, making her gums recede. Without a doubt, Lucia will eventually lose both new bridges. Her money was completely wasted by ignoring my advice.

Gina

We saw Gina a couple of years back. She had an upper premolar that could not be saved, and we had to extract it. We warned Gina that if she waited, a premolar on the left would start hurting, and soon need a root canal. Gina waited until the tooth hurt. (Why do humans procrastinate?) But instead of coming to me, she decided to go to a dentist that supposedly offered heavily discounted fees.

That dentist did a root canal and a crown on Gina. It went alright for a while, until the whole thing cracked off at the gumline. The reason Gina was given such a low price is the dentist left out an essential part of treatment- a cast post to strengthen the root against fracture. Without a post, the inevitable happened. I am guessing even at the discounted price, Gina probably paid at least $1800 for this failed treatment.

But if it were just the money she lost, it would be bad enough. Gina waited so long to come to me after the fracture that bacteria reinfected the root canal, and Gina lost the tooth. She was out all the money she paid for the root canal and crown, the money I charged for extraction PLUS she has another toothless space in her smile!

And today…#3

Sabrina

Last month I worked up a case on Sabrina where her teeth would be moved by an orthodontist, assisted by implants placed in strategic positions to act as anchors for the braces. This case will require a high degree of cooperation between myself and the orthodontist. There are only a few orthodontists I would trust with a case like this. Sabrina was referred to one nearby.

What did Sabrina do? She checked her insurance list and instead went to a “participating” orthodontist in a corporate clinic. This orthodontist never contacted me, despite requests to do that. He is supposed to be putting on brackets today, as I write this. We have not decided where the implants should go, nor planned anything about the case. Corporate dentists like this guy don’t have time to consult with general dentists. They are typically bonused to start new cases, and they don’t want any consults to slow that process down. Will the case end in calamity? I hope not, but I am not optimistic.

It is hard to comparison shop for dental treatment. The price of procedures is only a minor part of the equation. More important is what procedures you will be billed for, whether they are appropriate, and how competently they are done. Internet reviews can be doctored, and there is no Consumer’s Report on dentists. In the end, competency and honesty of the dentist matters more than fees for procedures. You really do not save any money on a procedure at a cheap price if the procedure is inappropriate, or fails!

July 30, 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

35 Years Licensed to Practice

A Trip Down Memory Lane

The year was 1980, and the place was Augusta, Georgia. It was 35 years ago this May that I learned all my doctoral requirements had been satisfied, and I was cleared to graduate from the Medical College of Georgia School of Dentistry.  A few classmates thought our Dean was bluffing about holding them up because of unsatisfied gold filling requirements. Those guys had to stay during the summer and do nothing but pure condensed gold fillings.  But like me, about 60 of my 65 classmates were deemed ready to take the Georgia State Dental Board for which we were all preparing in June.

Graduation was a big deal at Medical College of Georgia, as it is in most college towns. I think MCG rented the Augusta Civic Auditorium to have enough space. First, there were some Associate degrees awarded to the radiation techs, dental lab techs, and physical therapy assistants. The vast majority of degrees awarded were Bachelor’s, awarded to nurses, physical therapists, medical lab techs, and dental hygienists. Finally, the PhD, MD, and DMD degrees were awarded to the researchers, physicians, and dentists. Each of us had to walk on stage, shake the President’s hand, and receive our sheepskin. I was quite a prankster at the time, and searched high and low for a hand buzzer to use on the college President. Guess it was fortunate I never found one! Degrees in hand, we medical and dental graduates were ready to take the Georgia State Boards.  Without a state license, it was impossible to practice anywhere and actually earn a living! 

Few patients realize how difficult the various state dental boards were at that time. In Georgia, applicants had to do resin, amalgam, and cast gold fillings on live patients. We were tested on a lot more procedures in the lab, and had to take a written test on Georgia practice law. My patients faithfully showed up for the Boards, but not everyone’s patients did. A patient not showing for this important appointment may mean the young dentist could not practice for another six months, when the Board was given again. It was not uncommon for us poor dental students to have to pay patients bribes in order to show up for this grueling test.

There were several Board examiners on the clinic floor those two days, and I was lucky enough to get an amiable one. He was building a swimming pool behind his house, and we bantered back and forth about that subject during my work on patients. It kept him in good humor, and our conversation relieved the incredible stress on me that this important exam imparted.

Casting my gold filling in the lab went flawlessly, and all the examiners seemed to like my work. Soon a notification came in the mail that I had passed! I was legal to practice, at least in Georgia. Later, while in the Navy, I took North Carolina’s and Tennessee’s Board for good measure. (I never practiced in either of those states, but still keep my license active in North Carolina, because it was such a hard exam!)

People don’t remember how tough the early 1980s were. We had double digit inflation AND unemployment.  Interest rates were approaching 20%! America was in a funk with hostages in Iran. An actor named Ronald Reagan had yet to be elected president. The future looked pretty dim for us new graduates. Hardly any older dentists needed younger associates. The few ones that did, sure didn’t want left-handed graduates like me.

The harsh reality was that almost no place in Georgia could support additional dentists in 1980. Only one county in South Georgia was actually recruiting for a second dentist to serve its population of 10,000 people. With demographics like that, I thought, what could go wrong? (Plenty that I did not realize at the time.) I spent my life savings on a piece of land that was a cantaloupe patch. I still remember going to the county courthouse and registering my new dental license by signature in a huge bound book over 100 years old. Two local banks lent me a good amount of money at high interest to open a new dental practice in the small rural town that was the county seat. Just my luck that year the county had its worst drought in 75 years, and crop failures went with it. 1981 was not much better. After my fledgling business folded, I spent the next seven years of my life trying to get the guts to buy my second practice. That initial business failure was quite the personal defeat for me. But all one can do is keep trying, and eventually success will come.

Well, here it is 35 years after graduation. I have actually treated patients for 38 years of my life. You see, Medical College of Georgia’s Dental School was quite progressive for the time, having us starting to treat patients in the spring of our freshman year. So by 2017, I can claim to have healed fellow humans for 40 years!

My professional life has been quite an adventure, meeting dentists at conferences all over the world, as well as treating indigent patients in Lebanon and Peru.  I will have to admit these last years practicing in the beautiful Henry Building sure beat my early days in South Georgia, the Navy, and a couple of Atlanta clinics that will remain nameless.

God willing, I intend to practice for at least 50 years like three dentist-heroes of mine. My wife may not let all those years be full time practice. It is rewarding to relieve human suffering, and put diseased tissues back into healthy condition. Even after thirty five years, having the legal privilege to cut and repair human tissue is an awesome responsibility. I have helped a lot of patients all these years. If you are reading this, you are probably one of them!

Kim Henry, D.M.D.

May 9, 2015

 

Why I don’t use Invisalign

There are a number of clear orthodontic aligner systems on the market. The name that patients know best is Invisalign®, which is a product of Align Technologies. Patients always ask me for Invisalign, and I tell them I don’t use that brand of aligners. Why not?

Invisalign costs a lot more than other aligner systems. Therefore, patients must pay a lot more to have this particular brand of aligners.

Align Technologies wants dentists to take a weekend course and be “licensed” to use Invisalign. It is ridiculous for a dentist like me, who has been doing orthodontics for over twenty years, to have to spend nearly $2000 for such a proprietary weekend course, the sole purpose of which is to teach me how to use their product!

Align Technologies utilizes a team of lawyers who try to put other aligner companies out of business for alleged patent violations. Aligners have been used for many years before Invisalign was invented. I don’t like corporate bully-boys who try to eliminate their competition this way.

Align Technologies is a publicly traded company which must answer to shareholders. Their business is to sell as many aligners as possible. I have seen Invisalign treatment plans that were overly aggressive and had little chance in success. Many inexperienced dentists get into trouble when they are “sold” such cases by Align Technologies.

Finally, as you can see in the “Lab Work Made in USA” section of my website, I support American labs and American jobs. Align Technologies has offshored its aligner fabrication to Mexico, and its clinical staff planning the cases to Costa Rica. The labs I use for aligners are 100% U.S. based.

Consumers are too easily influenced by advertising hype in printed media and television advertising. Just because something is highly advertised does not mean it is the only game in town, nor the best deal.  Patients don’t know which brands of dental materials work best, nor which are the most cost effective. Leave that decision to the experts- the dentists who use them!  Be assured that I will always be concerned for the health of your mouth AND of your pocketbook.

Do Gadgets Make Good Dentists?

A prospective patient came by one day to interview me. She was looking for a new dentist for her family. She and her husband were intelligent people and owned two successful businesses. This woman was doing her best to select a good dentist for her family- or so she thought.

The questions she asked centered on what expensive gadgets I had bought for my office. Did I have digital x-rays? Did I have a laser? How about one of those expensive CAD-CAM machines that makes crowns while patients wait?

Sorry to say, I am a conservative business owner who is leery of incurring debt to buy expensive and unproven equipment.  I must have disappointed this woman, as she did not return. Doubtless she found a dentist with most of the expensive gadgets she thought were standard for good dental treatment.

It is unfortunate, but a lot of people think many expensive gadgets = quality dental care. This is in no small part due to manufacturers’ propaganda. In the high-overhead professions of both medicine and dentistry, it is a hard sell to get docs to buy expensive new equipment. Nobody wants to be an early adopter who spends $50,000 on an invention that doesn’t live up to its expectation.

So the trend is to first advertise any new expensive technology directly to patient populations. Without a professional background and access to scientific journals, it is easy for the average patient to be convinced that some new gadget is the greatest thing since sliced bread.

The next step is for manufacturers to post an online list of dentists who bought their product, so patients can view and patronize these practitioners. In this way, manufacturers seek to reward dentists who make a large purchase of their new equipment.

Am I against new technology? Absolutely not. My problem is that much of it does not work out to be practical or economical. Someone has to pay for this expensive stuff. Invariably it is the patients via higher fees. It is instructive to look through the “For Sale- Used” ads in my dental journals and see what is available. Invariably I encounter expensive items that were highly touted three to four years prior, but did not end up being a worthwhile investment. These gadgets sell used for pennies on the dollar.

Would digital x-rays save my patients radiation over my top-notch film and equipment? Not much, if any. Intraoral digital x-ray sensors are uncomfortable in the mouth and cannot be sterilized. The chief convenience is immediate reading by the dentist.

How about spending thousands of dollars for software to trace and measure parameters of skull x-rays for orthodontics? It would save me time, but considering the fact I analyze about eight such x-rays a year, would it make sense? Hand tracing and measurement take me a little time, but the result is just as good.

Would investing over $100,000 in a CAD-CAM machine to make crowns in the office do better than my lab technicians? Not from the examples I have seen. And the crowns still have to be custom-stained to look authentic. But again, it is convenient for the dentist not to have to schedule a second patient appointment for cementation.

Would a $40,000 laser work magic on my patient’s gums? Well, it is not true that patients don’t need anesthetic injections before using lasers. These machines cut very slowly, and stink when they do. The only convincing use I have seen for lasers is to cut gums around implants, where my electrosugery unit cannot be used.  In dentistry at least, lasers seem like expensive toys.

By now I am sure you get the picture. With high enough patient volume, there are a few technologies that sometime make sense for a practice. These are few and far between. For every technology that proves itself in medical or dental practice, there might be nine that disappear because they do not live up to expectations.

In dental and medical practice, if you don’t get diagnosis and treatment planning right, no technological marvel in the world will make up for it. Technology is no substitute for experience in surgery. The main effect of technology is to increase doctor productivity. In general, the number of high-tech gadgets in an office is not a good indicator of quality of treatment you will receive.

The Great Silver Filling flim-flam ~ or~ Straight talk about a good Filling Material

“Aren’t those silver fillings you put in people’s mouths poisonous?” Patients ask me questions like this weekly.  They think they might be victims of an unsafe filling material, but they are instead victims of self-serving fear mongers. There is so much misinformation about health issues in the news media, it is no wonder many patients are confused.  It seems like the purpose of reporters is to scare us to death with sensationalism, rather than to inform us.

Silver amalgam fillings were placed by the Chinese as early as 1400AD, and in Western countries since the early 1800s.  This material has saved countless of millions of teeth from extraction.  Silver amalgam is economical, easy to place, and durable.  Current formulations are about 59% of a mixture of silver, copper, and tin, and 42% mercury.

“Mercury!  Isn’t mercury a poison?”  This is always patients’ next question.

Yes, if you ingest elemental mercury or sufficient amounts of methyl mercury, it is.  Many common everyday items contain amounts of dangerous elements, bound together in stable molecules.  Elemental chlorine gas is lethal if inhaled.  Bound together with sodium, it is the table salt you ingest in food every day.

It is true, silver amalgam contains mercury, but it is bound together in a stable alloy that poses no health risk.  Silver fillings have been the subject of countless scientific investigations. Although it is true that trace amounts of mercury are released in heavy chewing, the amounts are inconsequential and have not been found to pose a health hazard.  Eating fish, especially tuna, releases more mercury in your body than do silver fillings.

The most elemental mercury is released from silver fillings during their placement and during their removal from teeth.  Now think about this: my assistant and I remove old silver fillings and place new ones in teeth during much of our workday.  If silver fillings are so dangerous, don’t you think dentists and their assistants would be the people who were very ill?

Now why on earth would people try to scare you into thinking fillings in your mouth are poisoning you?  There are two reasons- publicity and money.  Please examine people’s motives before you believe what they say.

If one researcher concluded that drinking tap water was a dangerous health risk, it might make headlines on the news. If ten researchers concluded that drinking tap water was safe, do you think you would hear about it?  No- It wouldn’t be news, because it would not be contrary to what anyone believes.  It wouldn’t scare anyone, nor generate any publicity!  For a researcher, claiming silver fillings cause a variety of serious illnesses is a sure way to be an instant celebrity. It also gains publicity for his university employer, which increases the researcher’s chance of promotion.

Likewise, if a dentist tells you that your silver fillings are safe and should stay in your mouth, he will earn no money from you.  However, if a dentist acts unethically and claims your silver fillings are toxic hazards and should be replaced, he stands to make money from replacing them with more expensive types of fillings.  Think about it!  Where is the motivation?

Two beautiful new and polished silver amalgam fillings, alongside an older amalgam on the left.  Amalgams like these may easily last 20 years, and often 40 years in the mouth.

Now that we have gone over all the reasons why amalgams are safe, why should you consider using them in your mouth, instead of types of fillings?

1. Amalgams are cost-effective.  They have the lowest cost per year of useful life of any filling material.
2. They are easy for the dentist to place, even when there is moisture.
3. It is relatively easy to get a good contact between a silver filling and an adjacent tooth. Inadequate contacts can cause food impaction and gum disease.
4. Post-op sensitivity is usually minimal and short-lived.
5. Silver fillings actually seal better with increased time.
6. They are more decay-resistant than resin-based or resin-cemented fillings.
7. Silver fillings can be repaired or added to.
8. The amalgam material is not so hard that it wears the opposing natural teeth.

Silver amalgam fillings remain the most durable filling material for back teeth after gold.  Gold fillings are wonderful, but are more complicated to do, and cost several times as much as silver amalgams. Science has made great improvements in white resin fillings, but such fillings still do not last nearly so long in back teeth.  It is not rare for silver fillings to last 30 years, and it is possible for them to last 60.  There is no reason why you should have silver fillings replaced for health reasons.

Dr. Kim Henry

May 3, 2002