In that vein, my goal is to provide my patients with a treatment plan for high quality dentistry based upon estimates of longevity–for both the patient and the restorative material. Bottom line: if one wants to keep one’s teeth, treatment must be completed BEFORE it hurts and BEFORE the tooth breaks–that is, BEFORE there is any symptomatic reason to do so. The reality is that, sometimes, even modern dental techniques can’t save a fractured, infected tooth.
The alternative to this rule is to relinquish the personal control and timing of preemptive care and subject oneself to the rigors of rescue dentistry (to be discussed in Rule of Thumb #4) after the tooth/teeth become symptomatic. Rescue Dentistry is the “bread and butter” of the General Dentist–because the need for treatment is now obvious to the skeptical patient and “required” for the relief of pain and/or suffering. For the dentist, the dreaded “sales pitch” is now unnecessary–there is nothing more to prevent or preempt; for the patient, there is now a complete loss of control over the ability to plan and the freedom of choice; for the tooth, it may be too late; and for the wallet, whether there are remaining dental benefits or not, is a moot point. I like to refer to these teeth as: Christmas Eve Teeth–I think the reason should be reasonably self-explanatory.
Though it can be effective, rescue therapy is less predictable, more extensive, more expensive and much shorter-lived. The most complicated treatments that my patients need are a direct result of the long-term reliance upon short-term dental treatments based on silver/mercury amalgam fillings or tooth-colored plastic fillings and sealants.
For reasons I cannot fully fathom, many new patients to my practice are under the impression that once a tooth is filled, it’s “done”. Nothing could be further from the truth. My favorite analogy goes like this:
Why do we change the oil in our cars every 3-4000 miles? We could just wait and replace the engine every 15000 miles when the engine seizes and save two or three trips to Jiffy Lube!
Fillings work pretty much the same way. If one waits too long to update or upgrade a filling, the tooth will “seize” (see Figure 1 and 2) by fracture or root canal abscess. Rather than wait for the bitter end of a filling’s life, it would be preferable and more predictable to replace it when the first signs of deterioration are evident.
Dentists are routinely taught that we should educate our patients about the benefits of “preventive dentistry.” But the longer I do this, the more I see that preventive dental work fail because of personal habits, dietary challenges, systemic health issues and just plain wear and tear. I prefer to think of myself as a “Preemptive Dentist.” If one wants dental work to last, one needs to consider the length of time it is expected to do so–the patient’s life expectancy! Patients must also be forewarned that dental benefits are never going to cover 100% of the cost. The average plan supports and pays for the “least expensive alternative treatment”, usually referring to a less expensive option that will last for a 5-7 year period–the average amount of time an American spends in any one place of employment. (If you think about it, when the tooth “seizes” the patient is conveniently working somewhere else and likely subject to the restrictions and limitations of a different benefit company.)
The tooth in figure 1 above was identified 6 months earlier as old and potentially weak. Figure 2 shows a fractured tooth with a moderately sized tooth-colored, bonded composite filling. The patient with the teeth in figure 3 had been advised to have them crowned 4 years earlier due to the deterioration and age of the fillings (both more than 20 years old). The molar (larger tooth on the right side of figure 3) was completely split down the middle–the patient delayed treatment because THERE WAS NO PAIN, NO SYMPTOMS. When the patient finally “caved” to my recommendations (“badgering” in his words!) and agreed to update his dental work, the molar needed to be removed because the crack (and bacteria) had extended into the root canal and split the root.
Cost is often cited as a barrier. Six months beforehand, the tooth in the figure 1 above could have had a new filling (~$250), or a crown ($1200-1500). Now that the tooth is fractured and painful, the restorability of the tooth is in question and the rescue therapy to correct it will cost ~$3500 (including gum surgery, root canal therapy AND build-up and crown). The out-of-pocket cost will be roughly $2500, or 10 TIMES the total cost of the new filling with no benefits. If the tooth cannot be saved, the tooth can be removed and replaced with an implant: ~$5000.
Wouldn’t it be cheaper and better to just change the oil?
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Next time: Rule of Thumb #2