Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

November 17, 2015

What is the best crown for a front tooth?

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Dr. Hall,
What is the best crown for a front tooth?
– Asra from India

Asra,
The best crown for a front tooth is the one your expert cosmetic dentist is most comfortable with.
Creating a crown for a front tooth, if you want it to look perfectly natural, is a work of art, and you need to let your artist work with a medium that he or she is comfortable with, and also a laboratory technician that he or she is comfortable with. If I were doing it, I would do it with feldspathic porcelain, but other cosmetic dentists might select a different material.
But please note—the dentist needs to be an expert cosmetic dentist, an artist. In saying that I have cut out 98 to 99% of dentists. And actually, in India, you may only have a handful of dentists in the entire country who would qualify as expert cosmetic dentists. That’s an important qualification.
A dentist who is an artist, for example, would never select porcelain fused to metal for a front tooth.
Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

November 2, 2015

What is a porcelain upgrade?

Filed under: Porcelain crowns — Tags: , , — mesasmiles @ 2:54 pm

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Dr. Hall,
I have been looking on the internet without any help. I am having a new bridge put in with 3 porcelain crowns. Then on the list they gave me it also stated 3 porcelain upgrades. What is a porcelain upgrade what does it mean? I have looked and looked without an answer.
Thank you.
– Lisa from Florida

Lisa,
A “porcelain upgrade” could be any of a number of things. It is not something that is standard in the profession, but is peculiar to your dentist. There is some extra service in connection with this bridge that he or she is charging you for. Here are some possibilities:
1. The charge could be for a more expensive type of porcelain that is being included in your bridge.
2. It could be a charge for premium esthetic treatment of your bridge, if this is to go in the front of your mouth. In my practice, I charged more for a porcelain crown in the front of the mouth than for one on a back tooth, because it was quite a bit more work to get it to look beautiful and match the other teeth perfectly.
3. Although it is phrased as a “porcelain upgrade” it could be for a more expensive type of metal that is being used as a framework.
4. It could be for a metal-free bridge, meaning that they will use a high-strength ceramic as a framework for the bridge rather than metal.
5. It could simply be a way to jack up the fee, without any other rational explanation. You could have a dental insurance plan that restricts the fee that your dentist can charge and this could be his or her way to get around that.

The way they are putting it as an “upgrade” implies that it is an optional item. I would call the office and ask what it is for and then ask for an explanation as to why you should choose to have this upgrade rather than the standard service.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

October 7, 2015

These crowns are not the color they appeared to be when they were tried in

 

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Dr. Hall,

I have just had two all porcelain crowns made for my two front teeth, #s 8 & 9. The crowns were a wonderful color match to adjacent teeth and I unreservedly authorized them to be cemented in. After the cementing procedure, I looked in the mirror and IMMEDIATELY noticed a slight grayish hue to the teeth. I inquired about this, and the dentist stated that the cementing product he used was transparent in color. I have looked at the teeth in different light conditions over the past several days and STILL see this. Is there something in the cement or its curing that could have caused this?
– Sara from Florida

Sara,
Did the dentist try in the crowns dry? Or was there some type of try-in paste used between the crown and the tooth under it?

That is one possibility that could account for a difference in perceived color between the crowns when they were tried in and when they were cemented. If the crowns are dry, they don’t transmit the underlying color of the tooth as well as they would with a bonding medium between the tooth and the crown. Darkness, stain, or metal posts in the teeth underneath could cause a gray tinge to the crowns. What I did in my practice when my bonding cement was going to be transparent was use a clear glycerin to accurately mimic what the resulting color would look like when it was bonded.

If that’s not the case, then the only other explanation I can think of for a discrepancy in the color like this would be color metamerism, which is the property certain materials have to appear one color under one light and another color under another. Some porcelains may match the teeth under a cool fluorescent light but then won’t match in, say, daylight or under incandescent light. But a clear bonding cement made by a reputable manufacturer will not change colors upon curing and won’t impact the color of the final result beyond helping transmit the underlying color.

If the grayness is only very slight, maybe it isn’t really noticeable, and since both very front teeth are the same, it shouldn’t be distracting. However, if the grayness is significant and noticeable to others, I think your dentist should fix this. At his expense. It could be a great learning experience for him.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

September 30, 2015

How do you whiten porcelain crowns?

Filed under: Crowns for front teeth — Tags: , , — mesasmiles @ 5:09 am

 

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Dr. Hall,
I have several front teeth that have caps on them. I’ve had them for approximately 30 years. They are not white like I would like them. What would you recommend for whitening my “fake” teeth. I’m assuming they are porcelain, but not 100% sure on the material they’re made up of. They were put in with posts and each one is individual.
—Missy from Pennsylvania

Missy,
If you have caps (crowns) on your front teeth and they are white and they’ve been there for 30 years, I’m pretty sure they have to be porcelain. Nothing else would last that long.

Unfortunately, the only way to whiten crowns is to replace them.

There is a company that is promoting the use of porcelain veneers to cover over old crowns, but that procedure makes no sense for several reasons, one of the biggest of which is cost. With most dentists, the cost of a porcelain veneer is pretty much the same as a new porcelain crown, so why wouldn’t you just replace the crown? Even if the veneer is cheaper, it isn’t cheaper enough to make it worth it.

First of all, if these crowns are 30 years old, there is a decent chance there could be some leakage or even decay under them.

Second, pasting porcelain veneers over old crowns creates some problems. This is a tricky bonding situation, and the bonding between the old porcelain and new porcelain is hard to get very strong, and it tends to be susceptible to stain. And it’s not going to last all that long. If these first crowns have lasted 30 years, why not get new ones and try to get another 30 years out of them? That makes way more sense than bonding some veneers over them that might last another five years.

No, just replace the crowns. It’s time a dentist looked under them to see what is going on there. It’s bound to be at least stained. Have the dentist clean it all up and put on some beautiful all porcelain crowns that can be as white as you want them. Bleach the rest of your teeth first, and then get the new crowns.

But go to an excellent cosmetic dentist. This is a new smile you’re talking about, and you need a dentist/artist to do this right.

—Dr. Hall

Do you have a comment? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

July 20, 2015

I want CEREC crowns on my two front teeth

Filed under: Crowns for front teeth — Tags: , , , — mesasmiles @ 3:26 pm

Dr. Hall,
I broke my two front teeth in an accident, and they both need crowns. I really want the same day crowns, and my dentist doesn’t do them. Should I ask him for a referral?
– Nolan from Florida

Nolan,
You THINK you want same day crowns, but I’m not sure you really do.
Your answer to this question will tell me whether or not you want CEREC (same day) crowns for these two teeth. Which is more important to you–that they look natural, or that you take care of this in one appointment without having to wear temporary crowns?
Your front two teeth are the most important teeth in your smile, and most people would be willing spend a little more or go through a little more inconvenience to get them looking just right. CEREC crowns simply aren’t that esthetic.

Let me illustrateshould you do a CEREC crown on a front tooth? with a close-up photo of a front tooth.

Look closely at the coloration in this tooth. Notice that there is a tannish color present at the base of the tooth that fades out as you get to the halfway point. Notice also some subtle white splotches in various places. There are a couple near the base of the tooth and some more subtle ones near the center. There is also some gray that you see near the biting edge and wrapping around the sides of the tooth a little. And the very biting edge has a whiteish halo.

A porcelain crown for a front tooth is stacked in layers, and a good ceramist operating from good instructions from a skilled cosmetic dentist and maybe from a photograph will build all of these different colors into your crown, so that it looks lifelike. A CEREC crown, on the other hand, is milled out of a single block of ceramic and so will be missing all of this characterization.

Now there are some highly skilled cosmetic dentists who can paint on these characterizations and make a CEREC crown look more lifelike, but you’re talking about fewer than 1 in 100 dentists who can do this and have the equipment to be able to bake these colors on. And even with them, it is still not as good, in my opinion, as having the color embedded in the crown the way it is in a natural tooth.

I should mention also that this is really a job for a skilled cosmetic dentist. The vast majority of general dentists would not be this attuned to the appearance of these front teeth.

Now if you don’t mind having two front teeth that have a flat color and are fake-looking, then go with the convenience. The temporary crown that you have to wear for a couple of weeks is annoying. But I think most people would put up with that for the result of attractive front teeth.

If you opt for the CEREC crowns, you don’t need a referral from your dentist. It’s easy to find a dentist who does CEREC crowns–just search for CEREC crowns with the name of your locality also in the search box.

By the way, there are other brands of same-day crowns. CEREC is the most popular. There is also PlanScan and E4D, which use the same on-site milling technology.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 11, 2014

Repairing a porcelain crown

Dr. Hall,
My son has his four front teeth capped with the caps that have a white color in the front and the silver on the back. One of the crown is chipping revealing the silver under the white front. No dentist in or around town says they can help me without replacing the crown. Is there anything that can be done to simply make the front all white again without replacing the whole crown?

– Bobbi from New Mexico

Bobbi,
I have a couple of things to say about your son’s situation.

Yes, there is a way to repair a crown that is chipping and showing the underlying metal, but you’re going to need to go to a dentist with particular expertise in cosmetic dentistry and bonding technology. In Las Cruces that would be Dr. Brian Gilbert. Do a Google search for “Bright Star Dental” and you’ll find him. Over 95% of dentists are not going to know how to do this or have the equipment needed to do this.

The process is very similar to the technique I wrote about several years ago for repairing a porcelain bridge. The underlying metal has to be etched with a small sand blaster and then treated with a metal bonding agent like Panavia. The fractured edges of the porcelain have to also be etched either with the same sand blaster or hydrofluoric acid or both and then my preference is to treat it with a silane coupling agent. Then the metal has to be coated with an opaquer. The crown is then ready for bonding with composite restoratives, to match the color and surface luster of the porcelain.

But there is more to this situation than just repairing the crown. The question that comes to my mind is, Why is this crown chipping? You are writing on behalf of your son, which suggests to me that he is still young, meaning these crowns haven’t been on him for that long. The crowns are porcelain fused to metal, which is pretty strong. When they chip, it is usually because of some flaw in the making of the crown. And you say, “is chipping.” I’m going on sketchy details from you here, but your putting it that way suggests that this is a process that is occurring over time, not a single event. Is it going to chip some more? Something is either wrong with this crown, that it would do this, or there is something happening with your son that is particularly abusive to this crown.

And then I have the question, why were porcelain fused to metal crowns placed on your son’s front teeth in the first place? Dentists who care much about the appearance of their work will put all-porcelain crowns on front teeth almost exclusively, not porcelain fused to metal. I’m really questioning the dentist who did this work.

I’m admitting that my advice here is based on my trying to fill in the blanks with things that you haven’t told me explicitly. If I am filling in the blanks correctly, then here is what I would advise doing. First, I would go back to the dentist who did this and see if he or she will make this right by replacing this one crown for free. If that doesn’t work, then I would go to Dr. Gilbert and have him repair the crown. Then, when your son is college age, if he isn’t that age yet, I would replace all of these crowns with natural-looking all-porcelain crowns.

I’d be interested in hearing more about your case, if you care to write back.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

April 11, 2013

Finding a cosmetic dentist in the Cayman Islands

Hi there Dr Hall,
Many thanks for such helpful information on your website. Your support is greatly appreciated! I currently reside in the Cayman Islands, my front right tooth slightly overlaps my front left tooth. Is there anyone you could recommend in Grand Cayman, so many cosmetic dentists I don’t know where to start. I have visited one, whom suggested getting all my teeth whitened, then 2 zirconia crowns on both front teeth as sister teeth. Are there any other options to compare, or does that sound wise. I am 34 with 2 young kids and finally want not to be too embarrassed to smile.

Many thanks
– Denise

Denise,
What you’re telling me about what this dentist wants to do makes me nervous. The idea that he or she wants to do zirconia crowns on these front teeth rather than bonded porcelain makes me think that he or she is not comfortable with bonded porcelain. Bonded porcelain would be preferable to zirconia. Zirconia is great for back teeth or bridgework, but I wouldn’t recommend it for an esthetically critical situation on your two front teeth. And I would think the ideal treatment would be porcelain veneers anyway, not crowns at all. Doing two or more crowns on front teeth can put you at risk of breaking them off from lateral stresses.

I don’t understand all these cosmetic dentists you are talking about. I just googled cosmetic dentists in the Cayman Islands and looked at several websites and couldn’t find anyone I would trust with even the simplest cosmetic procedures, much less something as involved as what you are telling me. Even in the United States, fewer than one dentist out of fifty could do a beautiful job on your case. I would be surprised if you could find a dentist in the entire Caribbean area who could do a nice job on this. Quite frankly, I would fly in to Miami and have someone there do this. Dr. Sam Sadati near West Palm Beach is one I know personally who would do beautiful work for you. You could have your teeth whitened there locally and then get the two veneers or whatever your case requires done in Florida.

Why spend money to give you a mediocre cosmetic result and then possibly end up with damaged front teeth besides? Spend a little extra for a couple of trips to Florida and get it done right.
Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 11, 2013

Porcelain fused to metal crowns are ugly on front teeth. Why would a dentist do this?

Dr. Hall,
I had 4-front teeth crowned with porcelain over metal. I am VERY upset because I was not informed about the dark line that I now see?? I did go to dentist today & he is replacing 1-tooth w/ dark line, but after just a month of having these crowns, I noticed on the back of THIS PARTICULAR TOOTH a spot of METAL appeared. I think that is why he is replacing it. Is this a rare problem?? I wish that I had known my options!!?? How much does a crown w/ porcelain over metal cost?? I am in a small town near Tampa! I paid about $989 per crown; is that too much?
– Shirley from Tampa

Shirley,
Back in the early 1980s, putting porcelain fused to metal crowns on front teeth was a good idea. But not in 2013. There are now porcelain bonding techniques where porcelain can be bonded directly to the tooth instead of having to be bonded to a metal framework to give it strength. And there are new high-strength ceramics. So there is no longer any need for the metal foundation. All-ceramic crowns are plenty strong enough to serve just fine on front teeth.

In my opinion, a dentist who is serious about the appearance of his or her dental work wouldn’t even dream of putting a porcelain fused to metal crown on a front tooth. Not only does the metal make the crown look opaque, but you will have that awful dark line at the gumline. And if the dentist is successful in hiding that under the gum for now, in a few years the gums will often recede a little and the dark line will become visible.

So what you have is a dentist who doesn’t really care that much about how your smile looks. If you do, then you have a basic disconnect with this office. Now I want to be careful here, because many of these dentists who aren’t very concerned about the appearance of their work are excellent dentists. They are very engineering oriented and careful and thorough. They’re just not artistic. And this is the case with about 98% of dentists, maybe more – they simply aren’t artistically inclined at all.

So then what do you do about the four crowns you have? And my guess is that the dark line isn’t the only appearance-related problem with this work. They will have to be kind of opaque. I doubt they sparkle like natural teeth. And the shapes may not be natural. But replacing them with work from a truly artistic dentist will cost you another $1000 per tooth, and your insurance won’t cover that probably for another five years at least. But that is the only remedy. So when you’re ready to have them replaced, find an expert cosmetic dentist from our list and have this done right.

About the fee you paid – $989 is a typical fee for a crown. (Click here to read about costs of porcelain crowns.) The sad thing is that for that fee, or maybe just a little more, you could have had a beautiful all-ceramic crown that would have enhanced your smile rather than detracting from it. And about the metal on the back – remember that this is a porcelain fused to metal crown. They will often have a metal back. The metal back is actually gentler on the opposing teeth that chew against these teeth than the porcelain would be, and it shouldn’t be visible from the front. If you just have a spot of metal showing, then you probably had a thin layer of porcelain there over the metal. That shouldn’t cause any problem.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 2, 2013

Do you need a crown on a front tooth with a root canal treatment?

Just had a root canal on the tooth right next to the front tooth. Is it necessary for a crown to be put on ? Can a post only be put in and if so, repair the discoloration with a porcelain veneer ?
– Ann from New York

Ann,
There’s a simple answer to your question and a more thoughtful answer, and I’ll give you both.

The simple answer is that dentists were taught in dental school that if a tooth has a root canal treatment, it is weakened, and thus it needs a crown to strengthen it and prevent tooth fracture. Plus, after a root canal treatment, a tooth will turn dark, so a front tooth should have a crown to preserve its appearance.

The more thoughtful answer differs from this approach in two ways. First, on the “likelihood to break” issue:
– Yes, a tooth is weaker after it has had a root canal treatment. But there is a difference between back teeth and front teeth. Back teeth, because they have a flat chewing surface and cusps are prone to splitting – the chewing force comes down between the cusps and this pressure tends to force the cusps apart. A crown will prevent splitting of the tooth. A front tooth, however, doesn’t have these forces. The risk with a front tooth is that chewing creates a horizontal force that may break off the tooth. A crown, since it requires removing 1-2 millimeters all around the circumference of the tooth, will actually weaken it against these horizontal shear forces and make it MORE likely to fracture.

On the discoloration issue, yes, teeth with root canal treatments will discolor. However, if the root canal cement and the root canal filling material are carefully cleaned out of the inside of the crown of the treated tooth, that discoloration will take years to occur and will be mild.

My preference for a front tooth would depend on the amount of healthy tooth structure remaining in the tooth. If, say, 70-80% of the tooth is healthy tooth structure, I would recommend restoring the tooth simply with a translucent or white fiberglass post and composite. Then, when the tooth begins to discolor, that could be corrected with a porcelain veneer or a crown at that point. If substantial amounts of tooth structure are missing, I would use the same white or translucent post with an all-ceramic crown.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 1, 2013

Is she allergic to the metal in her crowns?

Dr. Hall,
I am 64 years old…had metal fused porcelain crowns (5 upper front teeth) placed 4 years ago. After countless dentist visits, a nightguard, a guard for my bottom teeth, tensing of the jaw, etc., I cannot stop grinding my teeth. I am constantly aware of these crowns with the sensations I feel in the roof of my mouth. Do you think that maybe I cannot tolerate the metal? Previous to these crowns, I had gold backed crowns for 42 years which I never had a grinding problem. I have no peace and I am ruining my bottom teeth. Could I be allergic to the metal? (only because it actually feels “itchy” at the roof of my mouth.)

– Mae in Pennsylvania

Mae,

I need a disclaimer because of not being able to examine you myself, but just going from what you are telling me, it sounds to me like you have two separate problems.

The itchy feeling around the metal backings to your new teeth could well be from a metal allergy. Here’s what I would do: Ask your dental office for information on the composition of the alloy used in the metal of your porcelain fused to metal crowns. The laboratory would have sent them what is called a “Identalloy” certificate, which lists all the metals in the alloy. If you see “Ni” among the metals listed – this stands for nickel, and nickel allergies are fairly common.

Are you sensitive to any metals in earrings, for example? Women who have nickel allergies need to wear hypoallergenic earrings, and they have to be careful with what metals are put in their mouth.

Let me explain these dental metal allergies. In the medical history that the dentist took before starting any treatment, he or she should have asked if you have any history of metal sensitivities, and if you have anything like that in your history, the dentist should have prescribed metals for use in your mouth that have no nickel in them. The problem is, those metals are more expensive than ones that do have nickel. There are three expense classifications of metals used in crown and bridge work. The highest is called “high noble.” The gold backing you used to have would be in this category. Other alloys have high platinum. This type of metal makes a finer margin and is more malleable, meaning that it can be made to fit the tooth the best. The second highest is called “noble.” These will have a higher silver content, but will have no nickel or beryllium, which are metals that can cause sensitivities in some patients. They are somewhat malleable and make a very nice fit to the tooth, but not as high quality as the high noble.

The lowest category is called “base metal.” These are very stiff alloys and tend to be cast with small gaps between the metal and the tooth, so they don’t fit quite as well and they aren’t malleable at all. They will have some nickel in them and sometimes some beryllium.

Your new crowns may have also disrupted your bite. The metal sensitivity shouldn’t be causing you to grind your teeth, But if you had crowns on five front teeth, that has a strong impact on your bite and your bite could be thrown off to where it is making you want to grind your teeth. If this is happening to you, I would wear a nightguard every night until the bite is adjusted to where you don’t grind any more.

A particular problem if you have porcelain crowns on your front teeth that don’t have a full metal backing is that the porcelain on the upper teeth is highly abrasive to your lower teeth, and you will gradually wear down your lower front teeth. So I would get this fixed.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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