by Paul L. Child Jr., DMD, CDT and Gordon J. Christensen, DDS, MSD, PhD
Dental clinicians frequently categorize treatment decisions providing potentially inappropriate
treatment plans. In our attempts to simplify treatment, we often group patients
into categories, such as edentulous, medically compromised, financially challenged, perio
patient, pedo, average/normal, as well as many other politically correct (or incorrect)
terms. In doing so, we risk overlooking many of the unique variables that each patient
possesses, and the many other products and techniques available to treat them. Many dentists
have a wide arsenal of solutions, procedures and products to treat a variety of patients.
Some even have a formula or recipe to know exactly how to treat each category of patient,
while others find it easier to use a few select products, techniques or procedures to treat
all patients, regardless of individual situation, which is often based upon treatment cost.
This approach of "panacea-based dentistry" is not only illogical and unethical, but seriously
limits the dentist and the patient.
Whenever we become aware of a new product or technique that is inferred by the manufacturer,
researcher or key opinion leader as being the "silver bullet" for a given patient or
procedure, or touted as the new standard of care, caution and anxiety sets in and causes us
to question the claims. Very infrequently has there ever been or ever will be a product or
technique that can be applied to all dental patients in all situations. The introduction or
over-hype of a new product or technique is no different in dentistry than it is in many other
industries. In an attempt to simplify the many different options, products and techniques,
dentists sometimes cope by defining the clinical situations in "black and white" terms. We,
like many of you, have discovered this to be far from the truth – dentistry is not just black
and white or even many shades of gray, but full of colors, variables and a three-dimensional
field of options with which we must become intimately familiar.
The purpose of this article is to address a few of the main areas of panacea-based
dentistry and help you determine what treatment or product should be provided for your
patients. For those who provide a panacea-based approach to dentistry, this article will provoke
thought and reconsideration to provide an individual-based approach to dentistry.
Factors Influencing Oral Rehabilitation
Often, we clinicians state to our patients something similar to, "If you were my mother, I'd
place (this product or technique) in your mouth." Other statements allude to the ideal treatment
option versus the "poorer option," emphasizing how less desirable the latter option is regardless
of individual patient situation. Interestingly, we sometimes see the same statements used on all
patients. While some of these statements are comforting to the patient, very few patients are
actually knowledgeable concerning what products or techniques are the best, as most simply
trust our judgment. It is the dentist's responsibility to provide adequate informed consent by discussing
all the treatment options, while considering the patients' individual situation. The following
factors must be considered when proposing and deciding upon the best treatment for our
patients. In addition to patient factors, we need to also consider material and product choices.
- Systemic health
- Patient life expectancy
- Financial resources and third-party benefits
- Aesthetic considerations
- Vital vs. non-vital teeth
- Previous trauma to teeth
- Patient psychological status
- Previous and current caries experience
- Periodontal health and condition
- Patient interest in treatment
- Many others!
Onlays vs. Crowns
Presently, less than two percent of all indirect, lab-fabricated restorations are onlays. For many
years, onlays and inlays were taught to a significant level in dental school. In fact, many of you
passed your regional board by prepping and seating a cast gold inlay. However, today it is evident
that our profession has decreased the emphasis from onlays to crowns. When a patient has a fractured
cusp or two (typically from a Class II amalgam or trauma, see Fig. 1), many dentists immediately
condemn the tooth to a crown, when an onlay would be the preferred choice in most cases.
An onlay should be viewed as a precursor to a crown, and we suggest that more dentists provide
this valuable service. Tooth structure can be preserved and the cost might be less in comparison
to a full coverage crown. Most third-party benefit organizations are now reimbursing for this
procedure. Onlays can be quickly and effectively provided to patients, due to the supragingival
margins providing easier ability to make an impression, and superior resin cements.
Endodontics vs. Extraction and Implant Placement
Unfortunately, we frequently hear from lecturers and new and experienced implant dentists
alike, that when a patient needs root canal therapy, they heavily encourage implant placement
instead of endodontic therapy. Their justification is usually that the tooth will eventually fail and
need to be extracted anyway. This panacea thinking is confusing to patients and might be
unscrupulous. Individual patient factors need to be considered. Evaluate the remaining periodontal
support, the restorative history of the tooth, the patient's financial ability, adjacent tooth
support, aesthetics, the patient's interest in saving the tooth and many of the other above-mentioned
Often, we see partially edentulous patients with teeth that are slightly mobile, some requiring
endodontics, that could easily benefit from root canal therapy and a removable partial denture
or fixed partial dentures or both. Instead, the patients are told that their teeth are hopeless
and that four to six implants are required on each arch, followed by a fixed-detachable implant
prosthesis or a full ceramo-metal fixed prosthesis on each arch. In such cases referring the patient
to an endodontist or providing the root canal therapy yourself needs to be accomplished before condemning the tooth for extraction and implant placement (see Fig. 2).
Periodontal Crown Lengthening vs. Implant Placement
For some dentists, implant dentistry is a seemingly instinctive treatment choice. This is
especially true when comparing cases in which a tooth can be extracted, the socket grafted, an
implant placed and when observing the simplicity of restoring the implant to the alternative of
periodontal crown lengthening. Implant dentistry appears to be a very popular choice when
considering the proven longevity of implant dentistry and the greater financial reward for this
treatment. Dentists are now more inclined to emphasize implant dentistry for patients rather
than providing simple periodontal crown lengthening. Examples are patients with a healthy
periodontium and a single tooth with severe decay requiring extensive bone removal which will
compromise not only the aesthetics but also the bony support of the adjacent teeth. Other examples
are patients with a tooth broken off at the gingival line (or below the gingival line) and the
adjacent tooth is an implant-supported crown (see Fig. 3). Often, significant crown lengthening
would be required to create an appropriate ferule for the long-term stability to the restoration.
Some dentists fail to provide or even offer crown lengthening to their patients for a variety
of reasons, including: the belief or observation that the body will provide its own natural
crown lengthening; the added cost to the entire procedure, which might influence the patient
to reject the proposed treatment; the added time for the entire procedure, which can take up
to three months, post-surgically; and even the decreased emphasis by the specialists themselves
in favor of the implant option. Regardless of the reason, patients need to be informed when
crown lengthening is the most appropriate treatment and the risks and benefits of the procedure.
Additionally, the surgically oriented and experienced restorative dentist can provide
simple crown lengthening at the time of the tooth preparation for a reasonable fee, increasing
patient acceptance and decreasing overall treatment time, while ensuring that the patient is
offered all available options.
Resin-based Composite vs. Amalgam
Composite restorations dominate most of the direct restorations being provided in the U.S.
and in many parts of the world. Amalgam, despite its continued support by the ADA and other
organizations, has been relegated to patients with minimal third-party financial benefits, government-
supported programs, children, or those who are financially challenged. Amalgam is
still taught in most U.S. dental schools; meanwhile, is outlawed in some countries. Amalgam
restorations face the challenges of fractured cusps and staining, however, they have a known
longevity that can last up to two decades. Despite the ongoing controversy about this material
and its unaesthetic properties, amalgam has withstood the test of time and has been proven to
be an effective restorative material. This is especially true in terms of its longevity compared to
resin-based composites and its moderate cariostatic properties. Without question, resin-based
composite creates superior aesthetic results. However, it is technique-sensitive, more expensive,
lacks cariostatic properties and typically results in deeper and more extensive decay after
a service period.
Although much more popular, resin-based composites do not enjoy the same overall success
rate as amalgam, in terms of longevity, recurrent decay and depth of decay. Despite this, resin-based
composite is reserved for our "best" patients and amalgam for our "worst" patients. If a
dentist believes that resin-based composite is the superior option, he or she needs to present it
to all patients regardless of their specific situation, discussing the expected longevity of the
restoration compared to other options. If a resin-based composite is properly placed, using a rubber
dam and well-established materials, the restoration might last up to 10 years. In some patients
with some dentists, it can last longer. However, in a patient with a moderate to high caries index,
the average longevity is somewhat shorter (about five to six years – see Fig. 4). Careful selection
of the dental materials, techniques used, with patient education and frequent monitoring, can
maximize the success rate of these restorations. Post-operative and continuing fluoride treatment
should be used to assist in preventing recurrent decay.
Chairside CAD/CAM vs. Laboratory-fabricated Restorations
Chairside CAD/CAM-based dentistry is continuing to grow and gain interest among
many dentists. It is reaching beyond simple inlays, onlays and crowns. The technology is
advancing into relationships with cone beam computed tomography (CBCT), surgical guides
and immediate implant loading. While highly exciting for the technology-oriented dentist,
some dentists shun this new direction out of disinterest, disbelief or ignorance. It seems as if
conventional dentistry has a competitor instead of an alternative solution. Most manufacturers
are predicting digital dentistry as a significant growth center in the years to come and are
investing heavily to be a part of the movement.
While not all dentists are interested in chairside CAD/CAM or digital dentistry, the technology
and its ability to produce highly acceptable restorations is proven. The dental laboratory
industry is incorporating much of the technology and learning how to work with dentists
who are using the technology instead of working against them. Many laboratories are converting
their business model to direct their solutions to other dental labs, instead of the dentist,
via digital scanning, design and fabrication for those labs. Dentists and their lab partners
should discuss what is best for their practice and recognize the available options. In some practices,
the chairside CAD/CAM model might not be appropriate. Intraoral digital imaging
alone might be the next logical step for such practices continuing to use the existing dentist-laboratory
PFM vs. All-ceramic
In the past 10 years, a tremendous amount of money has been spent making dentists and
laboratories aware of the newer, more aesthetic all-ceramic crown options. Advertisements
linking attractive women to the ceramic systems infer the absolute beauty of these new systems
compared to the gray or yellow appearing metal-based systems of the past. Improvements
to past ceramic systems, such as the addition of leucite, reformulation of lithium disilicate, zirconia
as a framework, monolithic ceramic options, as well as the rising cost of alloys, has
increased the use of these all-ceramic options. Despite this, porcelain-fused-to-metal (PFM)
still remains the number-one prescribed crown system in the U.S.
There are some dentists who refuse to use anything but gold alloy restorations (they are
dying with the gold), while others use only zirconia, and still others only use lithium disilicate.
The long-term success rates of many of these newer all-ceramic systems are being established
and clinical judgment is advised on knowing when to use them and when not. But to
use one system for all cases without providing the patient with options can be considered negligent
The aesthetic result of a well-fabricated PFM crown can equal that of any of the newer all ceramic
systems, with the added benefit of more than 50 years of proven success. However,
the laborious waxing, investing and casting are being replaced for the simpler CAD/CAM lab
systems that can be completed much quicker with consistent results. The dental ceramist/technician
is becoming a digital dental designer. It is highly recommended that the dentist and the
lab technician/ceramist discuss the available ceramic systems, including metal options, such as
conventional PFM (layered) and press-to-metal and when it is best to use each.
Other Areas of Panacea Dentistry
While only a few of the main areas of panacea-based dentistry are addressed in this article,
other examples include:
1. The placement of porcelain veneers on all patients desiring an aesthetic improvement
instead of providing a minimally-invasive approach that might include minor tooth movement,
enamel recontouring, bleaching or direct resin-based composite placement.
2. The general dentist business model of "everything under one roof" when some procedures
that the general dentist is not experienced in would be best treated by a specialist.
3. The approach that everything that has a flaw, fracture or
evidence of age should be replaced instead of conservative repair
4. The attitude and practice that only conventional-sized
implants should be used in patients when small diameter implants
(minis), as well as short/wide implants are viable options.
The common theme with all of the above examples is that
the dentist is limiting the options to themselves and patients by
using a "one or the other" approach.
Dentists should continue to educate themselves in all areas
of dentistry, learn of the many treatment and material options
available and provide a variety of services based upon research
and facts. We suggest that dentists provide informed consent to
every patient, reviewing all available treatment options, the
advantages and disadvantages of each, as well as the associated
risks and costs. Ultimately, educating patients and providing
them with the autonomy to choose the best option for their
individual situation is ethical and rewarding for dentists and
provides the best service for patients.