Monday, September 26, 2011

Crown vs. Anterior composites and honesty!

Hope everyone had a great weekend. Here in sunny Florida it is starting to cool down. Not too many 90 degree plus days and it feels nice. Football is in full swing and I am enjoying it. In the south, college football is a big deal. I remember living in San Diego and how Saturday was nothing special. I am glad to be back in the south.

I was reading John's blog about the weed eater and trying to return it and it made me think about a recent patient. This patient was a nice guy. He came in with a chief complaint that his front tooth was broken and that he would really like to get it fixed since he was in sales and it really made him feel self-conscious. #8 had a large fracture, no caries, and needed a large class four composite or a crown. I asked him if he had ever had it fixed prior and he said yes but the filling "came out." I told him that this tooth was on the fence between a very large filling or a full coverage crown and with his past history of having a filling and it coming out, I would first suggest a crown. He stated he really wanted to try the filling.

I do not know what you do, but if I really think it needs a crown, I will tell them I will do the filling but I cannot give them any reassurance as to how long it will last. It probably depends on how careful they are with it. I really hate saying “guarantee" because I doubt any other type of medical surgeon gives a guarantee on their work, but maybe I am wrong!

The patient stated he understood and would accept the risk of the filling possibly debonding or fracturing in the future. I know you might be mumbling, "Yeah but the patient never remembers that in six months or a year when it fractures again and it is all the dentists’ fault." Well, I did the restoration and he loved it and I sent him on his way.

On this blog, and just in general, we talk and hear about dentists dishonestly or unethically, which even once, is too much. It saddens me to see and hear these things, but I am a big boy and know it happens. However, what about patients being honest? I see it all the time, whether they are trying to get pain pills, free or reduced care or they want us to change a code or something to help them scam their insurance company. It goes both ways!

Well back to the story. Sure enough, about six months later he came back. The filling had fractured off. I put my guard up and got ready. I walked in and we started talking and immediately he started to say that HE screwed up and that I warned him and admitted he was chewing on a pen and bit down on it and the filling broke. I was so relieved. So many times the patient is complaining that it was just done and that they did nothing and it just fell out and it is everyone’s fault but their own.

I have been using a total etch technique and OptiBond Solo Plus for about ten years and have had very few issues with "spontaneous debonding.” The stuff works well, but I know there is always a chance it could happen. It might not be the gold standard, but it seems to always be ranked very highly in research reports.

So depending on the situation (a long time loyal patient or someone that only shows up every couple of years when something is broken), sometimes I cave in and do the restoration for free again but tell them this is it and next time it will need a crown, no questions asked. They always agree. Other times I will stick to my guns and remind them we discussed this concern and they will have to do a crown or pay again for the restoration.

Back to the other patient. I told him that I appreciated his honesty and it was refreshing to hear someone in today's society take responsibility and not try to blame others. I told him that he really needed a crown, but he wanted to try the filling again. I agreed and told him that for his honesty, I would give him a decent discount. He was very happy. This time, I modified the prep, placed some retention groves and etched and bonded to more enamel. Again, he was very happy. He told me he agreed he needs a crown and he will begin to save up for it and plan on the future to have it done. I wish these situations always went this well.

On a technical note, I typically do not place retention groves in my composites. I usually rely on bonding. I have seen some composites with pins, but they always seem to discolor and they were probably done a long time ago by a dentist who was desperate with the restoration falling out.

What are your thoughts?

Have a great week.



Megan said...

Great post. I think bonding is a great way to "Test" the strength of a tooth that may need a crown/onlay/etc. As long as the patient is informed and understands if it breaks it will need a crown, it is certainly better than leaving a leaky amalgam, etc.

I hate pins. We did lots of them in dental school but so many of them created problems with sensitivity and/or pulp damage. I have friends who did studies and the bonding strengths were higher than pin strengths so I never use them anymore. I don't see the reasoning behind a bonded (composite) restoration and a metal pin. I don't see many of them anymore and hope to never again.

Anonymous said...

Hey Guys,

It's all about COMMUNICATION!

Would you like a filling that might not last until you get out to the parking lot or a crown that will last for several years?

Oh, by the way, they both cost the same thing!!!

Bruce L. Cassis, DDS

navygatordmd said...

I feel our office is one of the best at communicating treatment options and expectations and that is my point, many people do not seem to remeber that converstation that is why it is documented. Not sure about the cost of your composites but there is a big difference in crown fee and composites at our office but not after it has been replaced a few times.

Anonymous said...

Whether a large composite stays in or not really depends on the bite and what they bite into. I will redo a composite that really needs a crown once for no charge and if they don't want to do the crown the next time they have to pay or the composite.

Anonymous said...

I think you are doing what is best-give the patient informed knowledge of the situation and the best treatment plan and if the patient denies, just document and do the filling-making sure the patient understands that it can come off and in that case crown would a good permanent solution rather than redoing fillings again and again.

Anonymous said...

Hi Doctor,

I recently got my tooth bonded as well after my filling broke after 14 years! I was eating pizza and it broke off. It was one of my front tooth on the upper arc, so I never used it to bite off an apple or carrots but shouldn't a pizza slice be ok?

Anonymous said...

Your story sounds as though I could have written it about myself - so often do I go against my better judgement ( if I can call it that) hoping that my optimism will win out over experience. Lately though, I have been concerning myself more with the question: "will there be enough tooth left to do a decent indirect restoration by the time the patient takes my advice?" or will we already have extended the prep so often to get better retention for a filling, that there's nothing left to crown? Like you, not always an easy decision for me - but WE are the ones with the professional knowledge, not the patient, so yes it is about communication but also about the EDUCATION of our patient.

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CarolJin said...

Nice blog! I have a friend that has been looking a great dentist to perform some composite bonding in San Ramon.

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