Important issues to consider in the provision of good dental care (Part 1)

I have previously posted my thoughts about “preferred provider dentistry” so I will not repeat my thoughts here. Suffice to say, my view is that providing quality dental care for a cheap price is not financially viable because it takes time to do what is required to achieve a quality result. Sadly, this is not a concept that the health funds seem to understand.

However, other influencing matters also impact the quality of dental care.

Implants

The advances in dental implants and grafting materials have provided many new and different options for dental treatment over the last 3 decades. Nevertheless, implants are NOT perfect. I totally agree that dental implants provide a fabulous alternative in some situations where teeth are missing. However, I disagree passionately where some dentists routinely recommend extracting teeth and replacing with implants, rather than restoring teeth (albeit with complex treatment). It worries me that there may be some dentists who “do not know that they do not know”.

There are many considerations when recommending to replace teeth with implants. Some are obvious primary concerns: eg periodontal health, caries activity and cost. However, what worries me is the possibility that laziness, lack of skills, ignorance or greed may impel some dentists to take the easier and more profitable option to extract and implant- rather than restore a tooth/teeth with methods that would have been considered standard complex dental treatment 30 years ago. Not only has the knowledge and skill been lost by many, but disturbingly, many dentists seem to believe that heavily restored teeth (including endodontically treated teeth with post/s, core and crowns) are doomed to failure. Yet after 50 years of practice, I constantly see most heavily (but properly) restored teeth still functioning decades after treatment. My philosophy is: “A well restored tooth is better than an implant”.

It is worth considering that we are still not certain how osseointegration works, and we have no practical way of treating peri-implantitis with certainty. We know implant failure rate is between 1% to 10% (generally depending on the surgeon’s expertise) and about 50% of implant placements can be judged as successful. BUT approximately 40% of implants are judged as non-failures - however they are also not considered successful. Thus there is a significantly high percentage of implants that are in a "grey" area of being neither successful or a failure. So in my mind, it is better to deal with “the devil you know (eg teeth, caries and periodontal disease) rather than the devil you do not know (eg implants and peri-implantitis)”.

In my view, it is therefore irresponsible to justify removing teeth and placing implants on the promise of “no further trouble” – especially if the treatment advocates removing large volumes of alveolar bone. To some degree, this philosophy smacks of the ill conceived concept of 100 years ago where young adults had all their teeth removed and dentures placed because they would have no more dental trouble. Simply said, it was a poor treatment choice and many people suffered over the following decades.

I emphasise that I fully support (and utilise) placing implants in required situations, but I do not advocate excessive removal of teeth in exchange for implants.

“Cerec” restorations

There is a tendency for some dentists to recommend Cerec restorations (CAD-CAM scanned and milled). These restorations may provide reasonable alternatives to laboratory made restorations, but after observing many, I have yet to see any that I would be happy with. I acknowledge that some practitioners (generally prosthodontists) can provide very satisfactory treatment using Cerec techniques. However, irrespective of quality, what I have observed is that many practitioners who have a Cerec machine seem to provide predominantly Cerec treatment. In many cases, I feel that a direct resin placement would be a more appropriate and conservative treatment. What I wonder is whether practitioners who have a Cerec machine, place Cerec restorations because they have to justify the cost of acquiring the machine? It concerns me that the cost of expensive equipment and software may “drive” the treatment advocated, rather than providing a cheaper, more conservative, and possibly better restorative alternative.

Further, having attended several “Cerec courses”, I fear that the generally recommended design of the tooth preparation seems to advocate a reduction of basic "retention and resistance form" principles in favour of rounded, more tapered preparations that make it easier for scanners and milling machines to produce Cerec restorations. Thus successful crown retention becomes more dependent of the direct bond of the cement rather than well established retention and resistance design of the crown preparation. This will always reduce the retention rate of crowns. Some practitioners I have spoken to acknowledge and accept a crown “loss” (eg de-bonding from the tooth) of about 5% to 10% whereas I feel a rate closer to zero is more acceptable and achievable.

Veneers

There are circumstances where conservative veneers could be used, but my observation of many veneers is that many are inappropriately utilised. The problems are numerous and revolve around: overhangs, lack of proper emergence profile, lack of retention, lack of consideration of general problems – eg Occlusal Vertical Dimension (OVD), bruxing, malocclusion and more. While cheaper than crowns, there are many situations where a crown is more appropriate, and also circumstances where resins would be more appropriate (at least initially – see Part 2 of this post). Further, veneer margins will often stain, and thus a short term aesthetic fix will often turn into a medium or long term aesthetic disaster. And of course, this also applies where veneers have caused periodontal disease or have fractured due to the above mentioned problems.

OVD and bruxing

There are times when the OVD of a patient needs to be modified to establish a more stable occlusal relationship and to reduce excessive stresses on some teeth and restorations. Failure to identify this will, more often than not, lead to long term problems for the patient and also for the dentist who provides treatment. Yet many times, OVD problems are so great and so overwhelming that dentists either disregard them; or do not know how to treat them and thus provide a “quick fix” treatment that will ultimately lead to a very unsatisfactory medium to long term treatment result. Furthermore, to properly treat such a problem is often very complex and expensive and demands considerable clinical skill and expertise – often involving multiple specialists eg prosthodontists, orthodontists, oromax surgeons, periodontists, etc. A “quick fix” treatment plan is usually unwise to recommend - given the variety of problems that might arise from such treatment (irrespective of the ability of the treating professional).

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With all this outlined (and plenty more that could be said), I would like to offer some practical suggestions – particularly to general dentists and even more particularly to recent graduates. This will be outlined in Part 2 of this post.