Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

June 29, 2017

What is the difference between a prosthodontist and a cosmetic dentist – a horror story

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Dr. Hall,

I recently had a full mouth reconstruction done by a very reputable prosthodontist, and although it was primarily for functional purposes, aesthetics were of great importance as well. How many people have the opportunity to have all brand new white teeth that match? It was exciting: however it was also a long and painful road. I brought in old pictures of myself to show him the color I wanted and the way my original work looked 30 years ago, and I said “this is what I want”—pretty straightforward I thought. Throughout the treatment, he kept telling me to he wanted me to be happy but sometimes when I would tell him what I wanted he would tell me I was wrong but he always said trust me—I’ve been doing this a long time.

When the first set came in, they were not anywhere close to the right color so he told me I picked the wrong color. We did three try-ins. The 3rd time I told his assistant that the top teeth looked dark, that they were darker than the bottom ones and I said that several times. Now mind you, I was trying in an unfinished set of teeth because they had their own lab to do the finishing and I had never seen unfinished crowns and bridges so I had no idea what they looked like before they were finished. Anyway, his assistant assured me that once their lab finished, they would be fine that the top and bottom teeth would match and to trust her. The bottom teeth were veneers, crowns and implants.

Now, to clarify part of the cause or my problem; every time we did a try-in, I couldn’t look at the teeth with my mouth open or see how they looked when I talked or with different expressions because the teeth would fall out which made it difficult to truly see the color or to see if the bottom and top teeth matched. So the day came to have everything put in permanently and there were 3 things I wanted to check, one being color! It turned out that one of the teeth was a little sharp. I said that and he said, “Hope, we’ve done just about all we can for you and I don’t think we’ll ever be able to make you happy; so maybe you need to find someone else to finish the job.” I was standing there unable to speak because all of my teeth would fall out, and all I wanted to do was leave—take all the teeth out and leave—but I couldn’t do that. I had no teeth and no money. I just kept thinking don’t do it just leave but how could I? I had no teeth. If I took these out, I would simply have no teeth. What was I supposed to do?

From that point, everything is a blur. I remember wanting to leave, telling the assistant that I was afraid to say anything else to him, and tears rolling down the side of my face when he started putting the bottom teeth in. Then I remember asking if they would put the top teeth in with temporary cement and she said no, that he wouldn’t do that.

Now, after all of this time, effort, and about $50,000, I have teeth that don’t match. The top teeth are darker than the bottom ones and I don’t know what to do. If it was the other way around, and the bottom ones were darker, then I could probably live with it, but it’s not. This is completely unacceptable—I have to have it fixed somehow. I personally think that he should re-do all of the porcelain over gold crowns and bridges so they match the veneers. Those are at least closer to the color I wanted. I feel so stupid for letting this happen, but I was in shock—like a deer caught in headlights but worse!
How do I go about addressing this with him? I’m very picky and the difference in color is DEFINITELY something I would have noticed, but not under those circumstances. I just froze, and I truly don’t feel it was my fault—I was under enormous duress at that moment.

As you can see, I’m very emotional and wordy which is not the way to approach this. Do you think this is something he should fix, given the situation; if so, please help me. I do not know how to communicate with him, let alone get the result I believe is fair.

– Hope from Michigan

Dear Hope,
So you have a very reputable prosthodontist. He is undoubtedly very good at what he does, from a technical point of view. But you have to realize that your appearance concerns are frowned on by institutional dentistry. This is a classic example of the prosthodontist mentality. You’re trying to tell him what you want. His response is: “Trust me—I’ve been doing this a long time.” In other words, he knows best, he doesn’t need your input on the appearance, and you’re a troublemaker for not just accepting that.

I have had several requests from prosthodontists to be listed on this website as recommended cosmetic dentists, and I have turned them all down except one. These are dentists thoroughly steeped in the dental school mentality that focuses on functional issues and trivializes concerns over appearance. This prosthodontist thinks it’s pandering to listen to your appearance concerns. You’re talking to a brick wall here. You’re saying, “I don’t know how to communicate with him.” That’s not the problem. He doesn’t want your input—case closed.

How to Get This Fixed

Hope—brace yourself here for some tough medicine. You’re going to have to stiffen your spine and go after this dentist. The good news is that you have excellent legal leverage here. You need to have the will to stand up to him.

I don’t believe you need to sue this dentist, but my gut tells me, as arrogant as he appears to be, that you are going to need to go to a lawyer and at least threaten to sue. You can try telling him that’s what you’re going to do and see if he will make this right for you financially, but I wouldn’t hold my breath waiting for a favorable response. What you want is for him to pay to have an expert cosmetic dentist fix the upper teeth so they look acceptable to you.

You are correct that, if there is a discrepancy in color between the upper and lower teeth, the lowers should be the darker ones. A good cosmetic dentist can get away with pushing the shade of the upper teeth maybe half a shade to a full shade whiter on the Vita scale and it will still look good. But not the other way around.

Here’s Your Leverage

What he did to you was malpractice. No, there is no suggestion here that there is any lack in the quality of the work. But he forced these teeth on you without your consent. Informed consent is a cornerstone of ethical dental treatment. You did not want these crowns on your upper front teeth put in, but he did it anyway.

I can see, by the procedures you have explained to me for his trying in these crowns, that he doesn’t care about your input. You said that the work kept falling out if you tried to look at it. Now there are try-in pastes made specifically for the purpose of holding the work in well enough that you can see how it looks. He certainly knows of these materials, but he isn’t interested in them because to him, he is trying the work in only to check the fit and to make sure he likes it. His practice isn’t geared toward taking into account anything about what you think.

I’m sure he doesn’t think he did anything unethical, and it’s not going to be easy opening his eyes to that, but a letter from a lawyer, educating him on this principle of informed consent, will certainly trigger a call to his malpractice insurance carrier. They should let him know that he is on very shaky ground, and they should be able to prevail on him to make this right for you. Again, what you want to ask for is for him to pay an excellent cosmetic dentist to take out the crowns on your upper front teeth and replace them. Here’s how you do that. First, find a lawyer who understands well this principle of informed consent. Have the lawyer write the letter explaining what he did wrong (basically, he is guilty of assault). Then, before you settle on an amount, I can recommend for you an excellent cosmetic dentist who can give your dentist a figure of how many crowns would be involved in fixing this and how much it would cost.

He may argue that he had your consent. And I’m sure that he had you sign some kind of form before starting treatment. But you did not consent to putting in these particular crowns. Yes, you let him do it, but you were under duress at the time, and consent under duress is not consent—this is a key legal doctrine. You were intimidated, not given reasonable options, and your reaction as you have described it to me indicates that this was not a voluntary consent. Your lawyer I’m sure will be able to explain the advantages of his just settling this matter rather than going to court and having to pay emotional and possibly punitive damages on top of the cost of just replacing the work.

Hope, I’m sorry I don’t have an easier path for you, but I have received hundreds of complaints similar to yours and I’ve coached many of those people through situations like this, and you are simply not going to be able to transform this dentist into a listening, caring cosmetic dentist by anything you say. In his own eyes and the eyes of many of his peers he is very good at what he does, and you’re just a peon. He has been taught that it would be wrong to listen to you.

– 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.

January 12, 2017

I have dry mouth ever since getting my new crowns

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Dr. Hall,
I had porcelain crowns for all upper and lower teeth. Ever since these were put in I have had dry mouth. This was a cosmetic procedure and I obviously regret doing it. I am wondering if there is anything I can do next. The dentist widened my bite so you can see more of my teeth when I smile and I try to remember to keep my mouth closed and breathe through my nose. I know the dentist can grind down the new crowns and try to match my original bite but not sure if that is really a good answer. Any ideas you have would be greatly appreciated.
– Randy from Pennsylvania

So you had crowns on all your teeth–we would call that a full-mouth reconstruction. You wanted more teeth to show, so the dentist “opened your bite.” In lay terms, he or she made the crowns “taller” than your natural teeth were.

Unfortunately, this hasn’t worked out so well for you and now you are suffering from dry mouth–called xerostomia in clinical terms. This isn’t just an annoyance but is a real threat to the health of your teeth, which I will explain below. In your case it appears to be caused by a condition that is called “lip incompetence,” which is defined as a lack of closure of the lips when the mouth is at rest. In other words, as you have explained it, you have to consciously try to keep your mouth closed.

This was a serious mistake by your dentist, and in my opinion he or she should accept responsibility for getting this corrected. If he or she doesn’t, you have a valid case for malpractice damages. Was your dentist so attracted by the high fees from doing 28 crowns on you that they jumped into this case and got in over their head? That is possible. Dentists don’t get enough training in dental school on full-mouth reconstructions. This is a highly complex procedure, and there are several post-graduate training institutes that offer this advanced training.

The proper way to do a full-mouth reconstruction, especially if the bite is going to be opened, is to first open the bite temporarily by some mechanism. What I did was build up the back teeth with composite to test how far I could open the bite. It can also be done with temporary crowns, though that commits you to having crowns. As a patient, you should wear the temporary crowns or the buildups long enough that you can be sure you’re comfortable with the new opening. And the dentist should never open the bite beyond the point of lip competence. This is one of the key things that needs to be checked–with your mouth at rest, do your lips come together naturally or is it a strain to close them? This is the test that is used to discover how much you can open it. You never go past that point.

Saliva a Defense Against Decay

Many people don’t realize that your saliva has important defense mechanisms against decay. Besides its washing and buffering action, it contains antibodies that fight decay bacteria and minerals that help remineralize early decay lesions. A serious complication of dry mouth is a greatly increased decay rate. And don’t think that your crowns make you immune to decay. It isn’t hard for decay to get in at the margins where the crown meets the tooth. Also, dry mouth exacerbates gum disease.

What to Do Now

With what appears to be a lack of prudence and care by your dentist in doing this case, I wouldn’t ask him or her to fix it but would seek a second opinion. I will email you privately a dentist near you that I would recommend for this second opinion–I don’t want to publicly give any more clues about your location. Yes, the bite needs to be closed down, but grinding the teeth down may not work. It may be that your case needs to be completely re-done at the expense of your dentist. Proper shapes of the teeth need to be preserved in order for you to have a healthy bite. And if the crowns have a metal foundation under the porcelain, you don’t want to grind through to the metal.

So go to the dentist I recommend. If he feels that this is your dentist’s fault, ask him to help you get satisfaction from your current dentist. Based on what you’ve told me, it sounds like you could take this dentist to court for malpractice, but it’s always better to give them a chance to rectify the 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.

September 21, 2016

Follow-up on Lyndi’s sinus perforation after extraction

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About three weeks ago I published a post about a patient named Lyndi who had a large sinus perforation after her extractions. She responded telling me about her subsequent experiences, and I gave her some additional advice. Here is a copy of the follow-up correspondence with her.

Hi again Dr. Hall,
I thought I would send an update. I waited the full 2 weeks and saw the oral surgeon for the follow-up this week. In the meantime, I developed yet another bad sinus infection. I had my family doctor call me in antibiotics because I was really scared this infection would spread. I am still having a ton of drainage, but only from the left side, where the perforation occurred. It still pours out my left nostril when I gargle and I have had that same drainage in my denture. The oral surgeon poked around with a q-tip, which was very painful, and said the hole is sealed. He also had me plug my nose and blow (I didn’t blow hardly at all for fear I’d make it worse). I questioned him due to the above symptoms and he basically crossed his arms and said “look I told you the hole is healed and you don’t need surgery. You should be happy.” I explained that news sounds great, but I’m confused and that was the end of my appointment. I’m so lost, still quite sick (4 weeks straight now) and really don’t know where to turn.

I don’t want to make trouble but I am extremely frustrated. I’m out of sick pay, so I’ve lost some pay and also had to work even though I’m sick. I am emotionally and physically exhausted. I still can’t eat well, can’t chew at all for the pain is intense and not worth it. I’ve lost at least 15 lbs and I’m small to begin with. I deal with this horrid smell/taste all day every day and I know it is the infection. I explained all this to the original dentist. Again, any advice would be much appreciated. I am a social worker and advocate for people every day, but for some reason I’m having trouble being heard in this situation.
Lyndi C.

I’m just going on what you were able to tell me, but the feeling I got from what the oral surgeon told you as opposed to what the ENT doctor told you was that the ENT doctor was the one you should trust. I don’t like it when doctors talk to you the way you are saying this oral surgeon was talking to you. Lecturing you that you should be happy? You’re not happy, and he should care enough to listen to why. There are two ingredients to quality medical and dental care–competence and caring. One without the other isn’t quality care.

Why don’t you just stick with the ENT doctor? It doesn’t sound to me like this oral surgeon cares whether you are sick or not or how much work you are missing. And the oral surgeon could well be buddies with the dentist. He probably gets referrals from her, so part of what is going on may be that the oral surgeon is trying to downplay the seriousness of your complications to protect the dentist.
Dr. Hall

Second follow-up, a couple of weeks later

Dr Hall,
You have been so kind to answer my questions and I appreciate it a great deal. I do still have a small hole that does not want to heal for some reason. I’m under the care of yet another ENT who appears to be taking me seriously. I wanted to update you as I finally received my medical records from the original dentist. My “informed consent” does not have a date, nor my signature. As a matter of fact, on the signature line it states, “reviewed with patient, not signed due to sedation.” Apparently they said they went over this with me the morning of my procedure, while I was under the influence of benzos, as I had been prescribed and told to take both pills 1 hour prior to my appointment. The dentist is refusing to pay my medical bills, saying they forgave my balance with their office in order to free up my money so I could pay the medical bills. I am completely aghast. I have called an attorney but still waiting for a call back. Any comments or advice is appreciated.
Thank you for your time.
Lyndi C.

My response:

From what you have told me, you have a very valid complaint, and I have some words of advice for you.
First, I would tell the dentist that you are contacting an attorney and let them know that they could make this a lot easier on themselves if they just pay your medical bills, if that’s all you’re asking. When you mention that an attorney is going to get involved, that should trigger a call by your dentist to her malpractice insurance carrier, and they would likely advise her to settle this before it gets out of hand and may reimburse her for any expenses involved in settling it.
You didn’t give them consent, so they are on pretty shaky ground. It seems reasonable to assume that you were too sedated at the time to sign your name, so clearly you were too sedated to give consent. But you have more grounds than just that, as, from what you have told me, they fell short of the standard of care in several important respects.
I may not be getting all this right, but I’ll make a list of what is in my head of their mistakes, as I remember your case and refresh my memory by scanning your emails.

Mistakes made by this dentist:

1. Not getting informed consent from you (consent under sedation isn’t consent).
2. Poor extraction technique resulting in bone fragments being left at the surgical site, a large sinus perforation, and infection (and, I suspect, material being pushed up into the sinus).
3. Not telling you on the spot that there was a sinus perforation.
4. Not beginning treatment of the sinus perforation until the day after.
5. Starting off with the wrong antibiotic.
6. Not changing the antibiotic in a timely manner.

They should compensate you for all the post-operative care expenses you incurred, not to mention the time you missed from work, in my opinion. And, if your case got into court, I think you would be entitled to significant pain and suffering damages and possibly a punitive award.
You also have remedies beyond just going to an attorney, and you might want to let them know you are aware of those. You could complain to the state dental board, and you could complain to the dental insurance company. The dentist would not want either of those to happen.

You could let the attorney know that you have shared details of this with me and that I said I believe you have a strong case. A requirement of any successful malpractice case is the opinion of another professional that the care was substandard. But hopefully the dentist will be reasonable and you won’t need to take that step.

The oral surgeon is very possibly a buddy of the dentist, which could be why you didn’t get very good care there and had to go to the ENT physician.

Dr. Hall

Question and answer go here.

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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.

May 5, 2016

On the appearance of my front teeth, my dentist just says “trust me”

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Dr. Hall,

I had my top 4 front crowns replaced and the new crowns are gray in appearance. They kind of match the rear teeth but in many conversations with the Dr. having the new crowns match the bottom teeth and whiter than the old crowns was very important. When the color was being chosen, I stated that it looked dark. The response I got was “trust me.” At the time the crowns were being installed, I again said they looked dark and the response was “they are perfect, trust me.” In the dentist’s photographs they don’t look terrible although the gray is clearly visible. In natural light I am extremely unhappy with them. So much so that I now consciously try not to smile. We met with the dentist and he again claimed that they looked great but stated that he would discuss with his peers and “make it right.” The next correspondence we received was a certified letter stating that he would not re-do the work and in his opinion they looked great. He claimed that his peers felt the same way, although without looking at anything other than pictures taken with a bright flash I question how that can be determined. What should I do?
– Glen from Massachusetts

I love your question and the situation you relate, because it illustrates so well the mentality of much of the dental profession. It’s an authoritarian attitude that is truly foreign to excellent cosmetic dentistry. What your dentist is telling you is that, as far as the appearance of your teeth, “the dentist knows best” and “who are you to tell me how your teeth should look?”

I have interviewed a number of great cosmetic dentists who create beautiful smiles. Some of them do celebrities. I will tell you that any smart celebrity simply wouldn’t trust a dentist with the attitude being displayed by your dentist.

When I do a website for a dentist who wants to promote himself or herself as a cosmetic dentist, I will have a long interview with them. One of the key things I ask them is how they create a smile design and what they do to make sure the patient is happy with any new smile they create. Without exception, these great cosmetic dentists are focused on how the patient perceives the appearance of the work. They view themselves as treating the self-perception of the patient. In the ethics of the cosmetic dentistry world, that is the problem the dentist is treating. If the teeth don’t look great but the patient has no sense of embarrassment over it and smiles broadly with no self-consciousness, then there is no problem. On the other hand, if the patient hesitates to smile or covers his or her mouth because they’re embarrassed over the appearance of the teeth, then that needs treatment. And the measure of whether or not that treatment is successful is that the patient now feels proud to smile. “After” photographs will typically show a relaxed, confident smile. Self-consciousness is gone. If that isn’t achieved, the cosmetic dentist would consider the treatment a failure. This is the universal attitude of these great cosmetic dentists.

However, to many in the dental profession, such concern over what the patient thinks is considered pandering to the patient and unprofessional. That is why this dentist, when you raised objections over how these crowns looked, replied simply, “trust me.” You see, your opinion doesn’t matter to him. And then, rather than making it right, he went to his peers. But any true cosmetic dentist would be appalled to let you out of his or her office with a smile they had created over which you were self-conscious.

You Are in the Wrong Dental Office

What to do? Well, for starters, you are absolutely in the wrong dental office. Any efforts you make in that office to get this right are going to be futile, because, based on what you have told me, this dentist is psychologically incapable of addressing your problem. So look for another dentist. Now there are many dentists who would have enough empathy with you to at least try to get this right for you, but if you really want to get it right, so that your front teeth look completely natural, you should go to an expert cosmetic dentist. If you let me know what city you are in, I could maybe find one for you close to you.

In my opinion, you should be able to get compensation from this first dentist to pay for re-doing the crowns, but I believe you are going to need to brace yourself to get tough with him. The first step is to find the dentist who will go to bat for you–you’re not going to get anywhere without a dentist who agrees with you. Then you would ask this new dentist to try to work with the first dentist to talk him into refunding your money. If that doesn’t work, you could go to a lawyer.

Informed Consent

Your dentist isn’t innocent here, in my opinion, and it seems that he senses that–hence the certified letter. However, he is bracing to defend himself on the wrong principle. The first principle of medical or dental malpractice is informed consent. If I have your story right, your dentist put these crowns in your mouth over your objections. That isn’t informed consent–it isn’t consent at all. That principle of informed consent is your leverage here and your case is analogous to the very first informed consent case that I was taught about in dental school.
informed consentMany years ago, there was a patient in Great Britain who had broken his leg and it had healed improperly. He went to a doctor for help. The doctor studied his case and consulted with his colleagues. They all agreed that the leg needed to be re-broken to heal properly, so they went to the patient and whacked his leg and re-broke it. The patient sued, because he wasn’t told what they were going to do and hadn’t consented. The doctors argued that it was their unanimous professional opinion that this was the treatment he needed. The court, however, ruled in favor of the patient, saying that regardless of how right they felt the treatment was, they needed to obtain the patient’s consent before proceeding.

This dentist of yours may argue that you nodded or gave him some signal that you would let him put these crowns in. But in my opinion, a strong-armed consent isn’t consent, and I think the dentist should be held liable, even if you did allow him to proceed.

This is the point you and your new dentist need to make to the first dentist, and hopefully he will be persuaded that what he did needs to be remedied, without your having to go to court.

And don’t get the idea that an expert cosmetic dentist is going to be way expensive. Interestingly, most good cosmetic dentists charge about the same for crowns that good general dentists charge.

– 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.

November 11, 2011

A dental horror story, and getting things fixed from here

In 2010 I changed going to the dentist I had gone to all my life as he was retiring. I am 62 now and I wanted to go to someone that was closer to my home. My insurance gave me a choice of dentists.

I went to my first appointment and my new dentist said I needed 4 crowns on my bottom back teeth replaced. He said they were over five years old, and they had decay. They had been on many years. Same with the four front teeth but he said he could put on whiter crowns but I would wait till the new year for more help from the insurance. I had the new crowns on my bottom teeth crowned in 2010 with CEREC porcelain and paid an extra $150.00 per tooth that they did not charge the insurance, just me. Now I find out that all porcelain crowns are usually put on just the front teeth.

Then the dental office said the front 4 were pre-authorized by the insurance. So I had all 8 front teeth prepared and got temp caps and waited for my crowns. They came back and he cemented them on. Then problems started. Besides finding out the work had not been pre authorized the back of one of my front teeth chipped off. I went in and he ground on it and sent me home. The next day half the tooth fell off. My husband left work and took me back and requested he redo both front teeth which he agreed to do. So I went back to the lab for color match again. The lab told me that they had not made any mistake on the first crowns and they were not very happy about it. So when the new crowns came in they were very thick on the backs and the dentist had to grind on them. After he ground for a while he stopped and said he could not grind anymore as it was getting too thin. So I went home and realized that everything I ate got stuck in between the two teeth. He said he would check with the lab but I would probably have to pay them to remake the crowns. I was shocked. A month went by and no word back. I finally called my insurance and they said to file a complaint. They did an investigation, sent me to a different dentist that said my bite was horribly off. The insurance finally said there was not enough evidence to show he did poor work on my front 2 teeth.

Then came a letter from my dentist that he would not see me anymore. I did not want to go back to him either but what about the problem and what about any guarantee on all the work previously done? I went on until it was time to go back for my checkup. I decided to go to a dentist that a friend went to and loved. He did his checkup and told me the blackish color on some of my new crowns was micro-leakage and bacteria under the crown had caused that. When putting on the crowns everything has to be as steralized as possible. So once again I filed a complaint with the insurance. In the meantime one of my front crowns broke off. I added to my complaint my tooth breaking off. So now I am waiting to hear back from the insurance again. This new dentist emailed his chart notes of his work. He did two root canals and crowns on my upper back teeth and he did not use all porcelain. He also included pictures of my teeth with the micro-leakage and the gap between my two front teeth and my bite being off with his recommendation. So I am waiting to hear back from the insurance and trying to decide whether or not to get an attorney involved as the insurance will only recover the money they paid if they agree with my complaint. In the meantime I have a temporary on my front tooth. This has been a nightmare. Will you please give me your thoughts on this?
– Corinne from Utah

If you go to a new dentist who says that all of a sudden you need a lot of work, something is wrong. Frequently, the old dentist was negligent in either not diagnosing correctly or in doing patchwork dentistry rather than comprehensive dentistry. But it could be that the new dentist is taking advantage of you. If that happens to anyone, I would recommend getting a second opinion from a dentist you know is up-to-date. Don’t rely on your insurance network – find another dentist on a private pay basis, a dentist who has a modern, clean office, that appears to be high quality, and get a second opinion and compare notes. Say as little as possible about your situation and nothing about what either dentist said. Don’t even identify the dentists, but make it clear that when you have the work done, you are going to use a dentist in your insurance network. You’re just looking for an honest opinion from a dentist you feel is up-to-date and who you know has no stake in the outcome. If you can take copies of your x-rays, do so, but remove any identification of the dentist. If you have to, just pay for additional x-rays. It’s worth it, to get to the truth.

Another problem people have is relying on dentists in their insurance network. These are not usually the best dentists. The dental insurance company usually picks them because they are the cheapest. (Read more about preferred providers here.) And while I am not in a position to say whether or not your crowns needed to be replaced, I am suspicious, from what this dentist said about the crowns being over five years old, that the dentist was merely taking advantage of a known insurance company standard that they will pay for replacement of a crown after five years, and maybe there really wasn’t any decay.

It appears that you were victimized by this dentist and all the crowns that you may not have needed and the poor workmanship. And if that is the case, I would seek some compensation from this dentist.

Here is what I would advise. Before going to an attorney, I would ask your husband to demand a refund of everything you paid and threaten, if the dentist doesn’t cooperate:
1. to go to an attorney and
2. file a complaint with the dental board.
I would also see if the dentist who examined the faulty dentistry would stand behind you on this dispute. That is key to getting any settlement from the dentist – having another dentist who can vouch for the faulty work.

If the dentist will settle with you, hopefully you can avoid going to court. But if the dentist resists, then I would talk to a lawyer.

About using porcelain crowns on back teeth, that isn’t an issue here. There are porcelains that work well on crowns on back teeth. I have a CEREC all-porcelain crown on one of my lower molars and it works fine. It depends on the strength of your bite, the position of the tooth, and the type of porcelain used.

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.

July 28, 2011

How to get a refund from the dentist who screwed up.

Dr. Hall,
In November 2009 I had a crown put on my number 8 front tooth. My tooth was slanted from sucking my thumb when I was little, and this was to fix that.

About 3 weeks after my crown was put on my tooth was really sensitive to hot and cold. I was told that was normal for the first few weeks. About 4 months later my tooth was hurting so bad that I had to go to the ER! The next day my face swelled up and I was out of work for 5 days. When I went to another dentist, they told me that my tooth was infected and that I would need a root canal and a new crown. I was like WHAT??? how could this happen? She told me that I had an open margin and it was from the crown not being placed properly.

I called the first dentist, who did the crown, and I told the secretary the situation. I told her that i deserved my money back because for his mistake i have to pay for another crown and a root canal!! she said that once the crown was in my mouth it was my responsibility!! I said even if it was a failed job???

Is he liable for this? Shouldnt he pay?? I have seen the xray and the open margin is huge! ! If he we re to have taken xrays at the end of the job he would have seen the open margin and knew it had to be redone.

At the time I was making payments on the crown and paid a little more than half. After I found out about his mistake i told the office i was not paying the balance . About three months later I got a notice saying he was suing me for the balance! I couldnt believe it ! I of course filled a countersuit and when I went to the small claims court his lawyer told me if i drop the counter claim then the dentist would “forgive my debit”. I said NO I want the money that I paid him and his lawyer said “Well he is not willing to do that.” The case now has to be handled by the superior court because civil court can’t deal with things like this.

My question is should this guy have fixed his mistake? Because of him I was in the most extreme pain I was ever in, I had to miss days of work, I had almost a dozen appointments ( emergency room, doctors and dentist visits), my face swelled up so bad that I could barely see and I had to get a new crown and a root canal . Please let me know what you think!

– Sarah from Massachusetts

You have quite the story!

I have to qualify this because I can’t judge this without seeing. But just going from what you’re telling me, yes, your former dentist is liable for violating the standard of care. The most important thing to check when a new crown is being seated on a tooth is to run the explorer around the margins and make sure there is a good fit to the crown. Usually a dentist won’t take an x-ray before seating a crown, but they always need to run that explorer completely around the margins of the crown and check for any open margins. But having the x-ray you have is good documentation showing his negligence.

The problem, though, in many cases like this is that the dollar amounts involved make it impractical to involve lawyers and to go to trial. But here are a couple of things you can do to increase the pressure on this dentist to refund your money:

1. Threaten to complain to the dental board. Not as serious as a malpractice suit, this is still something that the dentist is strongly motivated to avoid.
2. Have the new dentist help you. A call from one dentist to another, verifying that there was indeed a problem with the work, can be very persuasive. In a trial, you HAVE to have an expert opinion of a dentist to back up any claim of negligence. Your word isn’t good enough.
3. Have a lawyer write a threatening letter. Rather than pay for an entire malpractice case, just having a letter from an attorney can get the dentist to take your complaint more seriously.

Dr. Hall

Click here to read more about porcelain crowns on front teeth.
Click here to ask the dentist a question.


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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 9, 2010

How much risk, really, of nerve damage with wisdom tooth removal?

Filed under: Wisdom teeth — Tags: , , , — mesasmiles @ 12:33 pm

Dr. Hall,
I am 37 and have always been very nervous about getting my wisdom teeth out. Recently I got a small infection in one of my lower wisdom teeth that is slightly covered with tissue. This caused me to get my wisdom teeth evaluated. They did a 3D scan of my wisdom teeth and said the top 2 would be easy but the bottom 2 are close to the nerve. One wisdom tooth on the bottom is pushing on on the second molar but not covered by tissue and the other bottom wisdom tooth is not pushing on the second molar but is slightly covered with tissue. The oral surgeon said that they were both close to the nerve but the one that is pushing on the 2nd molar is slightly closer, about 1 mm away from the nerve. I was wondering how risky is 1 mm of space between the tip of the root and the nerve? What are my chances of it being damaged? And if my chances are high of damage…..will it be slight or could it be severe? Thank you very much.
– Tiffany from Ohio


Because of the legal climate in this country, the smartest thing for oral surgeons and other dental specialists is to overstate the risks involved in these procedures. Risk exaggeration is a great way to help insure that they won’t be the target of a malpractice lawsuit if something goes wrong.

So you come to me for a little more honesty, and that’s what I’m here for. Here’s the story on the risk of damage to the inferior alveolar nerve – the nerve that runs to the jaw and the lip – with a wisdom tooth extraction. If the nerve truly is one millimeter away from the tooth, and you have an experienced oral surgeon who has taken out hundreds of wisdom teeth, that is a very minimal risk. In order to damage the nerve, the surgeon would have to take the tooth out and then drill down into the bone another millimeter, and why would they do that? Or they would have to break the tooth and then make the mistake of applying downward pressure on the remaining root fragment in an attempt to get it out. They are all taught techniques for avoiding that downward pressure during an extraction.

I have taken out wisdom teeth that were sitting right on top of the nerve, with no space between the nerve and the tooth, and never had a permanent nerve injury. On rare occasions, the nerve would be fine right after the surgery, but then the next day it would start to feel tingly or abnormal. In those cases, there is swelling that is pressing down on the nerve, and I would need to prescribe a steroid for a few days to control the swelling to avoid compressing of the nerve. But if the nerve is protected by even one millimeter of bone, there isn’t really much chance of even that temporary problem happening. I even had one case where the nerve ran right through the middle of the tooth. I was able to split the tooth around the nerve without nicking or severing the nerve. However, the operation stretched the nerve, which damaged it, but the nerve was able to repair itself over time.

I hope this is helpful. When a wisdom tooth gets infected, there is little choice but to have it out. Moral – tell all your friends and your friends’ children that if there is any chance of wisdom teeth causing problems later in life, have them out when you are young (like under 25) when the operation is much easier on everybody.

I hope this is helpful,
– Dr. Hall

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.

May 10, 2010

A seriously botched $25,000 smile makeover

Dr. Hall,
Recently I had $25,000 worth of porcelain crowns on both my top and bottom teeth-paid up front. I went for my consultation, picked my smile style, and told the consultant that I wanted a white bright smile that looked natural. I was given something to lighten my bottom teeth. I also had a metal bridge replaced so that it would match my upper teeth. All top teeth were crowned. After extensive xrays and mouth impressions, I was fitted with a temporary set of teeth. I was told that by wearing the temps, I would be able to see how my teeth would look, the shape and size, and color, in case I wanted to make any changes in my porcelain crowns. I was also told that I was the one who had to be happy. Two weeks later, when my crowns came in, the first thing I noticed as they were on the table was that they looked dark. I commented on this, but the girl who was to put them on said that they would look different in my mouth. When she put them in (not cemented) she told me to be careful when I sat up to look in the mirror because they were not in yet. From the moment I looked at them, I said “They are too dull!” I continued to say this, even as they were falling out and I could see I had no teeth left on top. By the way, I went in because my front teeth had been bonded years ago and had been chipped away by my bottom teeth. Other than that, I had strong, white teeth. As I continued to say I did not like them, she said suggested we go outside in the natural light with a mirror. Even on the outside, I kept saying I did not like them and that they looked dull. She told me that my eyes were playing tricks on me because I was used to the white temporaries and that once on, I would see a difference. We went back in and I looked in the big mirror above the sink in her lab. One of my front teeth feel on the floor and she picked it up and watched it off…. I was about to cry. Then the girl who cleans the teeth stepped in and said how I would love them once they were in and polished up. Never once did the doctor I paid the money to come in to see what was going on…Never once was I offered an option like, “Do you want them whiter?”

I was so frustrated and upset. I felt pushed against the wall about the matter, having no teeth in my mouth and being convinced that I was seeing things. Needless to say, she cemented them in. After they were in, the doctor came in and started trying to level my top and bottom teeth. Once he found out I was unhappy, I had to tell him, he told me to wear them a week and come back and he would finish … He said we want you to be happy.

After a week, I went back. In the light I had also discovered that the bridge I had replaced did not even match the other teeth. The girl said, You have a metal bridge (4 teeth @ $1700) so it’s going to be different. I explained to the doctor that I had tried to tell the girl before she put them in I was unhappy with the color… He said ” Well we have to be fair to everyone, the lab, the workers ,,, no way can we redo what we have done.” He then said maybe he could remove the stain on my porcelain crowns to match the white bridge. I am suppose to go back in a week. He said if the lab used a certain stain, this might be possible. I am so upset. I trusted these people. I don’t know what to do. My husband is going to go with me this next visit. I have to go back. I can’t eat with the crowns because they have not been level and are very painful. Any suggestions? Thanks for any help!
– Sandi from Texas

If I am sizing up correctly what was done to you, based on the story you have told, you are the victim of seriously unethical cosmetic dentistry. You were told that they would be sure you were happy with your smile makeover, but it sounds like they had no intention of actually honoring that promise.

Again, if I am sizing up this situation correctly, and if it happened the way you told me, you are dealing with very pushy people, and you are going to have to take a different tack if you are going to get anywhere. You have to be willing to get a lot more serious with your complaints and maybe get some legal help. Are you up to standing up for your own rights?

If these teeth were put in over your objections, then this is classic malpractice. A fundamental principle of health care is that all treatment is rendered with informed consent. When you didn’t consent to the treatment, and they put in the teeth anyway, legally, that amounts to assault. But if you are going to get anywhere, you have to have some steel in your spine and be willing to stand up to these people. And just having your husband go in with you to the appointment isn’t good enough.

My judgment would be that you will need to help this dentist see that he is legally on thin ice in order to get him to fix this. I would suggest getting a lawyer to write a letter that suggests that you may sue them unless they totally redo this for you and honor the promise they originally made that you had to be happy with how they look before they would put them in. Or, if you don’t want to do that, you could take this e-mail and that might help open their eyes. Then, if they don’t agree, you could go to a lawyer.

For additional help, I could line you up with a great cosmetic dentist not too far from you. If it were me, I wouldn’t settle for this dentist re-doing the work. I wouldn’t ever let him touch my teeth again. Instead, I would demand that he pay me to have the work re-done by someone more compassionate and skillful. At this point, do you trust him? I wouldn’t.

Good luck,
Dr. Hall

Other links:
Click here to find an expert cosmetic dentist
Click here to ask Dr. Hall a question.

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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