Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

July 3, 2018

Botched case by a very reputable dentist


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Dear Dr. Hall
This started about five years ago when I wanted to get a single crown for my front tooth (#8). The crown ended up being bulky and the color was off. After that, I was referred to a very reputable dentist. The first crown he did was too gray. The second crown he did was closer, but didn’t fit into my mouth because of a protruding lower front tooth. At that point the dentist told me to get orthodontic work. When I did that, I ended up with a gap.

I’m now shopping around for a dentist I feel comfortable with, and I feel very uncertain about this. I am not 100% sure these dentists are going to follow through with getting it right. My last dentist has a really great reputation. He charged me enormous fees, paired me with a reputable ceramist, and it still didn’t work. Strangely, as I interview other dentists, when they hear his name, I am forced to defend myself. If they see the work, they back off, but everyone assumes the patient is at fault. As if I somehow caused the poor looking crown. Or am just being too picky?
– Melissa from Southern California

Melissa

Melissa,
Yes, I’m very familiar with stories like yours. But it’s interesting—you say the dentist and ceramist had “great reputations.” Oh, there is such a difference between a dentist with a great “reputation” and a great cosmetic dentist, and likewise for ceramists.

If you do a lot of reading on my blog, you’ll learn that institutional dentistry—most dental schools, the American Dental Association, and the “reputable” dentists look down their noses at cosmetic dentists. They mock them, calling them “cosmetologists” and unprofessional. I was taught in dental school that, on issues of how the dental work should look, we should not listen to the patient but should use our professional judgment. To these academics and dental leaders, true cosmetic dentists are pandering to the patient and unworthy. Read the Wikipedia article about cosmetic dentistry, written by someone with this academic mindset, and you’ll get a flavor of this condescending attitude.

This goes to the heart of why I founded this referral service and this blog—to be the politically incorrect advocate for beautiful dentistry.
Here, read two of my blog posts that deal with this issue. In the first one, the patient didn’t like the result because the teeth looked too white and phony, but the dentist insisted that they were fine, basically telling the patient that her professional opinion should out-weigh the patient’s opinion.

In the second post, I answer a patient named Glen from Massachusetts who kept having reservations as his smile makeover proceeded. As he voiced those reservations, his dentist kept telling him, “trust me.” After the work was completed and Glen was still unhappy with it to the point where he was embarrassed to smile, the dentist sent him a certified letter where he relates his professional opinion combined with that of several colleagues that the work looks great. This contrasts with the attitude of great cosmetic dentists that they are treating the self-perception of the patient and if the patient has reservations about the appearance of the final result, the case is a failure.

This is what I see over and over again when someone gets a recommendation from a dentist in this institutional mindset for appearance-related dentistry. They get a great mechanical dentist who has a “great reputation” among his or her peers but is really psychologically unfit for appearance-related dentistry. True cosmetic dentists are outliers in the dental community.

If you can come to fully understand that and realize that you were victimized by this institutional mentality and referred to a dentist who had a great reputation with the wrong crowd, and now you are moving into a different world that plays by a different set of rules where everything depends on whether or not the patient likes the final result, you may find it in yourself to trust again.

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.

February 22, 2017

Should I get a radiolucent crown or a radiopaque crown?


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Hi Dr. Hall,

I came across your blog and read your very interesting response to a writer with root canal issues. I, too, seek your advice.

I had my lateral and central incisor teeth filed down for a bridge (missing the two teeth in-between). I changed my mind from having the bridge when I learned about some negatives surrounding it, and went back to the partial denture. I have been wearing the temporary crowns for almost 6 months now.

I ended up having to do a root canal on the central incisor and I have been told that the lateral will also need a root canal because it has been exposed for too long and I am getting sensitivity to cold. I am not keen on doing another root canal.

I read about pulp cap in your blog. That’s interesting. Does this need a special dentist to perform?

Could you also tell me which dental crown is radiolucent? I was interested in the eMax crowns (lithium disilicate) but I read that it is radiopaque and as such will block xrays and disallow evaluation of the tooth underneath over time. Could you please tell me if this is so? And if this is so, could you tell me which is the best material for my now vulnerable teeth. I have a lot of anxiety that I might lose them.

Thanks very much for your response.

Marcia

.

Dear Marcia,

I hope that you aren’t trying to micro-manage your dentist and make all these clinical decisions for him or her. One thing I worry about in providing all this dental advice is that patients, thinking now that they are armed with sufficient knowledge, will try to tell the dentist what materials to use or will obsess over these decisions. I hope you’re not doing that. When you tell me that you have been wearing temporary crowns for 6 months and have all this anxiety I want to tell you to let go and let your dentist make these decisions. Do the best you can with the knowledge that I provide here to find a dentist you can trust and then trust him or her.

It sounds like you’ve been stewing over these decisions, wearing these temporary crowns for so long, and now one of the teeth became hypersensitive and needed a root canal and another is getting that way. It surely is time to let your dentist finish your case.

You’ve latched onto this question about whether a particular crown material is radiolucent or radiopaque and have decided that you want a radiolucent crown. But you don’t know enough to be getting into the weeds this deeply. There are a number of factors that go into selecting a material for a crown, and you have a very imperfect understanding of even this one factor.

But since you asked, let me explain a little about this issue.

Radiolucency of Crown Materials.

The only type of crown that is radiolucent is a plastic crown, which would be used as a temporary crown. A radiolucent crown is one that doesn’t block the x-rays at all. So yes, you are right, that with the x-rays you can see right through it. The problem is that decay is also radiolucent. Decay would tend to start at the margin of the crown, and with a radiolucent crown it would be impossible to tell for sure what is decay and what is just part of the crown.

But, you say, a radiopaque crown blocks the x-rays and so you couldn’t see under it. Here’s where oversimplification is getting you into trouble. There are many degrees of radiopacity. The ideal would be to have a crown that is partly radiopaque, just like tooth structure is. It doesn’t block the x-rays completely, only partially, so you can see through it to a certain extent but it doesn’t look just like decay.

To illustrate, here is an x-ray of a patient showing four types of crowns plus composite filling materials, and you can see the variations in radiopacity. None of the restorative materials used are radiolucent, for the reason I gave above—radiolucency causes the most complications for diagnosis.
radiolucent and radiopaque crowns
On the upper, starting with the canine on the left, we have a composite filling that is partly radiopaque. Next, on the premolar, is an eMax crown. Yes, it is radiopaque, but it has a very helpful partial level of radiopacity that makes it easy to tell what is going on with the tooth. Next, on the first molar, is a porcelain fused to metal crown. True, you can’t see through it, but you can see what is happening on the margins, which is where you would expect recurrent decay to start. Finally, on the second molar, is a gold crown.

On the lower, the premolar has a composite filling, the first molar has a CEREC crown which is made of lithium disilicate, and the second molar has a gold crown.

My preference for crowns on second molars is gold, even though it is totally radiopaque. I have heard many dental educators and researchers state the same preference. I’m not going to go into all the reasons here for that choice. I only want to make the point that this radiopacity is not a simple cut-and-dried issue nor is it the only factor to be used in the choice of a crown material.

– Dr. Hall

Do you have a comment or a question or anything else to add? 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.

December 4, 2013

Why some people agonize over the choice of a dentist

Filed under: Choosing a cosmetic dentist — Tags: , — mesasmiles @ 6:18 am

This is a commentary on an e-mail exchange with a patient I am calling “D”, as he agonizing over choosing a cosmetic dentist. Here are links to the first four e-mails:
Agonizing over the choice of a dentist.
Agonizing over the choice of a dentist, part 2.
Agonizing over the choice of a dentist, part 3.
These first three were a back-and-forth while I tried to guide him through his case and picking a cosmetic dentist. Then, I heard from him again a year later, when he still hadn’t picked the dentist. Here is that last exchange. Read: Agonizing over the choice of a dentist, part 4.

Here’s a little analysis of what has happened with D and why he can’t seem to pick a dentist. He had these two front crowns from a dentist, Dr. Bill Dorfman, who was supposed to be fantastic. But they didn’t turn out that way. Now I know Dr. Dorfman and have seen some beautiful work he has done. But we have had two cosmetic dentists look at his work here and agree that it should be done over. It was just two crowns in the front, and maybe he didn’t take the case seriously enough or spend enough time listening to the patient. Whatever happened, it seemed the result was below his usual standards.

But now, D, having been burned, is trying to second-guess everything he is told. He wants to pick the ceramist and he questions every recommendation the dentist makes. So we had this comment he made at the end of his last e-mail: “It’s all very confusing!!!” Of course it’s confusing. The problem is that he simply doesn’t know enough to make all of these decisions. He has to just pick a great cosmetic dentist and trust him or her to make the right decisions for him. Even if he did have a dental school education and post-graduate training in cosmetic dentistry, you can’t micro-manage the dentist, looking over their shoulder and questioning everything. The pathway to a great result is trusting the cosmetic dentist.

We thank our advertisers who help fund this site.

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.

December 3, 2013

Agonizing over the choice of a dentist – part 4

Filed under: Choosing a cosmetic dentist — Tags: , , — mesasmiles @ 5:44 am

For background, this is an extended e-mail exchange with a patient I am calling “D”, as he agonizing over choosing a cosmetic dentist. Here are links to the first three e-mails from July, 2012:
Agonizing over the choice of a dentist.
Agonizing over the choice of a dentist, part 2.
Agonizing over the choice of a dentist, part 3.
These first three were a back-and-forth while I tried to guide him through his case and picking a cosmetic dentist. Then, last month, I received the following e-mail from him:

Dr. Hall,
Its been awhile and I still haven’t made the decision on my dentist yet. Do you happen to know Dr. Hans Scoble?
Thanks,
D

I wrote back:
D,
Why not Dr. Latner? He is one of the best cosmetic dentists in the country.
I don’t know Dr. Scoble. I’ve never heard of him.
Dr. Hall

And he replied:
He wanted to do all eight teeth. I just don’t understand that.

And I answered:
D,
If I remember right, eight teeth is the right way to do your case. Unless you’re just going to replace the two crowns in the very front.

Great cosmetic dentists identify very strongly with the quality of their work, and they don’t want anything ugly out there with their name on it. So I can understand if Dr. Latner doesn’t want to do your case if you want him to confine himself to six teeth. It’s simply not going to look right, and he doesn’t want to be a part of that.

I fear you are destined for trouble with your approach. There has to be a little trust between the dentist and the patient or you will not get a beautiful smile. It just doesn’t happen.
– Dr. Hall

After thinking about D and his approach here for some time, I wrote down my reflections on “Why some people agonize over the choice of a dentist.”

We thank our advertisers who help fund this site.

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 6, 2012

Sometimes you just have to trust your dentist

This is a follow-up to a question from Jamie from California about Fixing a Black Triangle.

So I went to a cosmetic dentist your site recommends about my black triangle between the 23 and 24. he said it was small and should not bond it because the gum in that area will be hard to keep clean and could become inflamed and not healthy in the long run. If he doesn’t want to do the bonding, should I go to another dentist? I’d really like to reduce the black triangle. He recommended getting veneers in twos for the space, but I’d really rather not ruin perfectly good healthy teeth for veneers at this point.

– Jamie from California

Jamie,
You’re saying that this black triangle is between teeth #s 23 & 24? Those are the lower right central and lateral incisors. I was thinking you were talking about UPPER teeth.

Does this actually show during conversation?

Now I need to be careful here, because maybe this space is really ugly, but I’m skeptical. I don’t have a photograph of your face, so I don’t know, and I’m going to need to make some assumptions in answering your question.

Having black triangles between lower teeth is not really abnormal, and I wouldn’t be inclined to treat them. Some people have them when they are young, and almost everyone has them as they age. I have them, and I have received numerous compliments about my smile. The lower teeth tend to be covered by your lower lip, and even when they aren’t completely covered, people’s attention is naturally focused on your upper teeth.

Have you had other people notice this black triangle? Or is this just something you’re looking at and you have an idea in your mind of how this is supposed to look and how it looks doesn’t measure up to that ideal?

I’d suggest getting a friend or two you can trust, and position them at a normal conversational distance, and have a little conversation with them. And ask them if they notice anything unattractive about your smile. Urge them to be honest with you, and hopefully you can trust them to be honest. And make a judgment from that about whether this black triangle needs treating.

A good cosmetic dentist addresses the cosmetic needs of the patient as the patient perceives them. But there are limits of reasonableness to this approach. I remember hearing Dr. Ronald Goldstein, who is considered by many to be the father of modern-day cosmetic dentistry, discuss the unreasonable obsession some patients have with the details of the appearance of their teeth. Patients, he said, should evaluate the appearance of their teeth at a conversational distance, and when they use a mirror to evaluate their teeth, should hold the mirror at arm’s length, so that they see themselves as others see them. Then he joked that when they would hold the mirror up close, he would adjust the fee to be inversely proportional to the distance between their face and the mirror. That brought a big laugh from the audience of cosmetic dentists, because they all are familiar with patients who have an inordinate obsession with tiny details in the appearance of their teeth that no one else notices.

And the dentist you went to mentioned functional problems with bonding – that you will create an area that will be difficult to clean. Essentially, from what he is saying, he would create a food trap. He is to be commended for his honesty and integrity. But I have a question for you. You said you don’t want to “ruin” perfectly healthy teeth by putting porcelain veneers on them. Why, then, would you want to ruin them by creating gum disease around them? A food trap is far more damaging to the health of your teeth than placing porcelain veneers, and could lead to the eventual loss of those teeth.

Getting good dental care is a matter of being able to accurately judge whether you can trust your dentist. It appears to me that this dentist is trustworthy – as a recommended dentist on our list he has to be esthetically sensitive. And he is pouring cold water on your idea, saying that the damage that would be caused by the treatment you want would outweigh any esthetic benefit. You could just trust him, which is what I think you should do, or you could shop around until you find an untrustworthy dentist who will actually do what you want.

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 17, 2012

Why you have to be able to trust your dentist

Dr. Hall,
I have a split tooth but the x-ray reveals a healthy root…my doc want to extract and I want him to save it! How do I convince a dentist to try something new like that described in your paper? Dentists seem to want to extract to solve all problems, use scare tactics and it’s hard to believe they are not doing it for the money since much more expense is involved in an extraction and insertion of a new tooth….I want to keep as much of me together as long as I can!!!

thanks
Mike from West Virginia

Mike,
This is one thing I worry about when I give patients these answers to their dental questions, that they will take this information and go back to their dentist and try to “convince” the dentist of one thing or another, or tell the dentist how to make their cosmetic dentistry more beautiful, or tell the dentist what type of filling or crown they want, different from what the dentist recommends. That will not work. The purpose of this website isn’t to help patients educate or change their dentist. What you need instead is to find a dentist with a philosophy that you are more comfortable with.

You aren’t going to convince your dentist to save this split tooth if he has told you that he wants to extract it. It would be misguided of us to even have me personally call your dentist and convince him to save it. I couldn’t do that because I haven’t examined you and for all I know maybe that is the only option here. But there are dentists who are strongly inclined toward saving teeth, and other dentists simply don’t want to do that. And this philosophy permeates their practice at many levels. If a dentist wants to save teeth at all costs, for example, he or she will need to spend focused study on the techniques for saving teeth, dealing with cracks in teeth, what to do for failed root canal treatments, advanced periodontal techniques, and a whole host of things. At the other end of the spectrum, if a dentist just wants to take out problem teeth then they won’t go through all that extra trouble. What point is there, then, trying to convince a dentist to save this tooth when he probably doesn’t even know how?

But it is not true that “dentists” in general just want to extract teeth. There is a wide variety of inclinations here. And I firmly believe, from my experience with the dental profession, that the vast majority of dentists are highly ethical people who honestly try to do the best for their patients. They have varying levels of skills and different philosophies. And if you have cause to believe that your dentist is just in this for the money, then you need to find a different dentist. There is no way to work around this trust issue. There is no way, as a patient, that you can check up on your dentist to make sure he is making the right decisions for your teeth. In this situation of yours, even I, as another dental professional, don’t know enough about your case to be able to say if your dentist is doing the right thing or not. You HAVE to be able to trust him. If you don’t, then find another dentist.

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 4, 2011

I don’t really think I had five cavities.

Dr. Hall,
I recently went to a new dentist to get my teeth cleaned. I floss every day and I brush my teeth in the morning and most nights also, I dont drink alot of sodas either. I take really good care of my teeth. My old dentist told me I had great teeth. I found it weird that the dentist I went to the other day told me i have 5 cavities. All of them were in my back teeth. I went and had them filled, which he filled them with the white ones.

Since then I’ve had alot of problems with pain. I’ve had him adjust my bite but it still hurts. I really dont think I had cavities at all though. Should I get an xray from before and bring it to another dentist to see if I even needed the fillings? I looked at the xray after he took it, I didn’t see anything, but of course I’m not a dentist either. I just never had pain before and now I do, plus with the care I take with my teeth I dont see how I could have had 5 after just going to the dentist last year and had none. Just wanting another opinion.
– Alicia in Tennessee

Alicia,
It is possible that you had cavities that the first dentist missed. I had an experience after I got out of dental school where I had a large cavity in my own mouth that had been there for quite some time and the x-rays taken at dental school missed it because they were taken at the wrong angles. But I think you’re reasonable to be suspicious. Yes, if you have reason, like you do, to be suspicious, I would ask for a copy of the x-rays and get a second opinion. But tell the second opinion dentist as little as possible, and don’t let the second dentist know the name of the first. I would just present the x-rays and show up and say, “I’d like a second opinion on this dental work” without planting any ideas like that you thought the work was unnecessary. A dentist who is hungry for patients will sometimes try to agree with a patient in order to convince a patient to quit the other dentist and become a patient. And a dentist who is personally acquainted with another dentist will sometimes hold back and feel a strong obligation not to criticize. To get the very best second opinion, you could visit a dentist in a distant city while you’re on vacation or something.

The post-operative pain you’re feeling also makes me suspicious. It sounds like the white fillings may not have been done correctly – not bonded correctly. Do you have pain when you clench your teeth together? Or is it just pain when you’re actually chewing something? If it doesn’t hurt to clench, but it hurts to chew, that’s an indication that something went wrong in the bonding process. If that pain persists, it may be necessary to replace the fillings to alleviate it. If it hurts to clench, then it’s probably that the bite just needs to be adjusted.

– Dr. Hall

Links: read more about pain after new fillings.
Click here to find a cosmetic dentist.

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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.

June 28, 2007

Pain after a crown

Filed under: Dental crowns,Pain in teeth,Root canals — Tags: — mesasmiles @ 9:53 pm

Dr. Hall,
I switched to a new dentist and during the required new patient evaluation it was recommended that I have a dental crown placed on my upper next to the last tooth. I had no pain in that tooth, but there had been some discoloration there for several years. The dentist did not perform a root canal. I have had continued pain in the tooth since the procedure. When I went back for the permanent crown after 3 weeks, I told my dentist about the pain. He repeated XRays and said everything looked fine. They only temporarily cemented in the tooth since I was still having pain. He said the tooth would probably get better but might take some time. I was unable to get a time estimate but finally was told maybe months. I said I could live with the pain for months if I knew it would eventually go away and that everything was OK. He said it probably would and if not I would need a root canal. This new crown has never felt right to me and still hurts just as much as it ever has. It has been 3 months now and I have had no improvement. The pain is usually mild as long as I don’t aggravate it. I am unable to eat anything on that side at all. The tooth and gum lines hurts if I touch it with my tongue. Last week the gum became inflamed, red, and extremely painful. The pain radiated to my ear. 24 hours later it was much better. It is still red, but not nearly as much. I am not sure I trust my new dentist. I need another expert opinion. I know that this tooth is only temporarily cemented in and I dread having to reaggravate it when the permanent cement is placed. Thank you in advance for your expert advice!
– Catherine from Texas

Catherine,
You haven’t told me anything that seems out of order, and my guess is that your dentist has done the right thing and you can trust him, at least from what you’ve told me. I myself have had a tooth that has hurt as yours has, and it went on for months while I hoped it wouldn’t need a root canal treatment, but it eventually did.
I would go back to the dentist and relate your experiences, and you will probably end up needing a root canal treatment. If your dentist can’t confirm that and is still puzzled, I would ask him for a referral to a root canal specialist, explaining that you don’t want to deal with the tooth pain. The root canal specialist will be in a better position to give an accurate diagnosis in a situation like this.

I hope this is helpful.
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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