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Medical Forum / General / Dentistry / June 2005Differing dental reports
Hi, This is a followup to a post I made some time back. My wife's old dentist diagnosed her with five (5) crowns. Her new dentist says she needs one (1) crown and two fillings. These reports we're based on the same set of full mouth Xrays. Now I would expect some variation, after all dentists are human, and some cases could be borderline. But this result astounds me. Maybe it shouldn't. In any case, I guess it's a good thing we went for that second opinion. Would reporting this to the state dental board accomplish anything? Jeff IF you get three more opinions, you might get three more differing opinions. There is a lot of art to this, based on science. Deciding when to crown and when not to will vary a lot from office to office.  Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > Hi, > [quoted text clipped - 8 lines] > > Jeff > Hi, > [quoted text clipped - 8 lines] > > Jeff No, and I don't know what it should accomplish. Are you assuming the first dentist was proposing to overtreat? As Dr. Steve M implies, this is an art as well as a science. Furthermore, you treat a patient, not a set of x-rays. I tend to be on the conservative side when it comes to treating, esp. if I think the patient will be back regularly for checkups. Discussing a treatment plan, esp. having the dentist explain the rationale for deciding on (for example) a crown instead of a filling will tell you something about a dentist's treatment philosophy, but it will also help you understand if there can be a real dialogue between what you are hoping to accomplish in treatment vs. what the dentist sees as ideal--in other words, if you can work together to a common goal. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 Ok, forgetting my comment about reporting to the dental board ( from your comments, it would be pointless in any event ). At what point good doctors, does one cross the line between "art" and "overtreatment"? I could bring a car into a shop, if one mechanic says a tuneup's all that's needed, and the other says it needs a major overhaul, do I just say, "ok, I understand, I could see where they both could be right". Is it really that fuzzy? In this case my wife's a new patient in both offices, has a prophy done, and Xrays evaluated, and two radically different diagnoses are offered. And the patient is supposed to nod and say "amen". If this kind of stuff happened in a car repair shop, the state regulators would be all over it to bust the perpetrators. It's not right, and it doesn't help the dental profession that this is condoned. Feel free to tell me how off base I am. Jeff If you get enough different opinions you will find 2-3 styles which emerge. You need to find a dental office you trust and who shares your philosophy and advance forward. Some offices will replace every restoration in your mouth (we can argue if this is preventative or to build revenues for the office), some offices will hardly ever place crowns, and others will place crowns when things break, or when huge restorations are beginning to fail. Sometimes a patient will have a broken tooth/filling and the tooth next to it has was appears to be a very old filling which is still serviceable, but beginning to look bad. Then, it becomes a discussion as to whether or not to restore it at the same time or not. In my office, I usually will offer about $150 off the second one done in the same appointment (so long as the teeth are next door to each other). I save time, so I pass it on to the patient. If you take your car to a mechanic and they do a compression test. 5 cylinders test at 550 psi. 1 is at 500 psi. 1 is 525 psi and the last one is at 495 psi. Some of the shops will want to open the block to replace pistons and rings, some will want to replace just rings, some will want to replace the entire engine, and some will say leave it go for now. Human beings are no where near as consistently built or maintained as automobiles. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > Ok, forgetting my comment about reporting to the dental board ( from > your comments, it would be pointless in any event ). At what point good [quoted text clipped - 11 lines] > > Jeff I don't see this as a "style" issue. Again, how can two dentists looking at the same tooth, come up with such different opinions. My wife's new dentist didn't say, "hey it's close, let's keep an eye on it." He didn't say anything about the tooth, period. I left out one tidbit of information. There was agreement between the two dentists on one tooth, both said it needed a crown. On the other six teeth ( four crowns,two fillings ) in question, there was no agreement. So maybe her new guy needs a new set of glasses. You brought up the issue of trust. That's fine how do you trust the dentist? Ok, you say get referrences. Fine, but does the person referring you know necessarily know anything more about the dentist than his nice office,staff, and caring attitude? All good things, but no guarantee he's looking out for your best interest. Don't get me wrong, a caring attitude is absolutely necessary as far as I'm concerned. I feel better about her new dentist after talking with him, but I still reserve judgement. FWIW, I had good referrences on both dentists. "If you get enough different opinions you will find 2-3 styles which emerge. You need to find a dental office you trust and who shares your philosophy and advance forward. Some offices will replace every restoration in your mouth (we can argue if this is preventative or to build revenues for the office), some offices will hardly ever place crowns, and others will place crowns when things break, or when huge restorations are beginning to fail. Sometimes a patient will have a broken tooth/filling and the tooth next to it has was appears to be a very old filling which is still serviceable, but beginning to look bad. Then, it becomes a discussion as to whether or not to restore it at the same time or not. In my office, I usually will offer about $150 off the second one done in the same appointment (so long as the teeth are next door to each other). I save time, so I pass it on to the patient. If I had a car with those readings( sufficiently high compression,,lowest within 10% of highest) , and my mechanic told me he wanted to rebuild the engine, I'd fire him. He's not looking out for my interests. In this case, knowing a little something about cars, I could ferret this out. "If you take your car to a mechanic and they do a compression test. 5 cylinders test at 550 psi. 1 is at 500 psi. 1 is 525 psi and the last one is at 495 psi. Some of the shops will want to open the block to replace pistons and rings, some will want to replace just rings, some will want to replace the entire engine, and some will say leave it go for now. " I would ad that neither are dentists opinions. "Human beings are no where near as consistently built or maintained as automobiles. " Jeff > If I had a car with those readings( sufficiently high > compression,,lowest within 10% of highest) , and my mechanic told me he [quoted text clipped - 10 lines] > to > replace the entire engine, and some will say leave it go for now. " So,,,,,,,,,,,,,,, you can make an informed opinion about automotive power plants based on your level of knowledge and experience. The same thing should be true about your mouth. You may need to discuss it more with the dentists to see what the decisions are based on. Do you deny that 4 different automotive shops would give 2-3 different opinions based on the above scenario? Hypothetically, lower the reading on the lowest cylinder to 480 psi. Now you will get a wider variation of choices. I would not tear down the engine on my road car for a 10% compression difference. If I was racing, though, I probably would. If I was running a hi-po street engine, I might. Even at 470 psi in the worst cylinder, I would hesitate to do a tear-down on a stock engine. I have two cars with 3-cylinder motors. If one cylinder was down in compression by 20%, it would get torn down. If one cylinder was down 20% in my V-8, I would hold off. Lots of choices based on what was normal for the engine, how it gets used, what is intended for the future, and what I am willing to put up with as time goes by. Fair enough, more discussion is good. However, at some point unless you are very knowledgeable in the area( I'm not ), you will need to defer to the dentist. My reason for getting a second opinion was the fact that my wife's previous( to the 5 crown guy )dentist ( in another state ), said her mouth was in good shape with a couple of fillings that needed monitoring, and would need replacement down the road. Now my wife takes reasonable good care of her teeth, so it seemed unlikely they'ed go to hell in that space of time. "So,,,,,,,,,,,,,,, you can make an informed opinion about automotive power plants based on your level of knowledge and experience. The same thing should be true about your mouth. You may need to discuss it more with the dentists to see what the decisions are based on. " Jeff P.S. I was referring to the family car, not something racing at Indy. Those things are torn down after every race most likely. Now if someone has buckets of money, and wants a mouth full of ceramic, then I guess the 5 crown guy would be their dream dentist:). >Fair enough, more discussion is good. However, at some point unless you >are very knowledgeable in the area( I'm not ), you will need to defer [quoted text clipped - 20 lines] >has buckets of money, and wants a mouth full of ceramic, then I guess >the 5 crown guy would be their dream dentist:). Cool! We are making progress towards being on the same page. Do you see how different people have different goals? This new dentist may not be best for your family. Remember that I do not have the luxury of knowing what the "old" dentist was thinking. I am playing Devil's advocate here. As dentists, we will often see big fillings on our patients who have been with us for many years. We will often choose to "watch" those fillings because we know the patient very well, and know they will take care If this tooth. If it fails, we know the patient will understand and come see us right away. With a new patient we have no idea what they are like. We often will choose to restore more teeth and try to make them "bullet-proof. Usually, complaints like yours are due to poor communication. We dentists sometimes fail to communicate properly. Anyway, you may be right and the dentist could be a jerk. Then, again he may have just failed to communicate properly. .. Stephen Mancuso, D.D.S. Troy, Michigan, USA I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. But not every mechanic can rebuild a race engine correctly. You need to be sure the mechanic is up to the task even if the race rebuild is what you want. Some are selling this service without the ability to deliver. :-( Fawks > Jeff > > P.S. I was referring to the family car, not something racing at Indy. > Those things are torn down after every race most likely. Now if someone > has buckets of money, and wants a mouth full of ceramic, then I guess > the 5 crown guy would be their dream dentist:). >But not every mechanic can rebuild a race engine correctly. You need to >be sure the mechanic is up to the task even if the race rebuild is what >you want. Some are selling this service without the ability to deliver. > >:-( >Fawks You get what you pay for; sometimes you get less. Now, where did I hear that, hmmm ? -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com > Ok, forgetting my comment about reporting to the dental board ( from > your comments, it would be pointless in any event ). At what point good [quoted text clipped - 11 lines] > > Jeff Overtreatment is unethical--period. Leaving aside the gray areas where different dentists would honestly disagree, it is difficult in any one case to tell if it is indeed overtreatment (though I'm inclined to, given just one side of the story). I once bought a dental practice from a former classmate who was relocating. Ordinarily there is a dropoff in business immediately after a dentist changes, but I found that all the patients that routinely got 6 cavities every 6 months suddenly got none. It is possible everyone's teeth suddenly got better but...you get the picture. Steve SignatureCut the nonsense to reply That's really all I wanted to hear. What frosts patients (me at least ), is when overtreatment is defended by dentists ( good,bad, and ugly ), as being just a matter of opinion. Circle the wagons mentality only makes everyone more suspicous and defensive. I want to trust my dentist, but it's not easy given some of the crap that goes on. Basicly I have to hope I get a good one, and after the fact, thru long experience, will I really know for sure. "Overtreatment is unethical--period. " Jeff I agree with Steve B. fully. Overtreatment is robbery. But, the difference between 5 crowns and one crown plus 4 big fillings is tiny. the difference between 5 crowns and one crown plus two tiny fillings is huge. The difference between 5 crowns, and one crown now, 2 large fillings now, and mentally watching 2-3 other teeth to see if they show signs of stress or cracking is tiny. There is no way we can be specific about your case over the internet. I just want you to see that it is wide gray line between the moderately large filling and the crown. Personally, I try to avoid it altogether by using onlays on the larger fillings and skipping the crowns altogether. You came here wanting to report someone to a dental board. That person may indeed be guilty of overtreating patients and deserve being spoken to by the board. That same person, may also, simply be offering the best treatment at his/her disposal based on his/her findings, knowledge, and experience. I am doing my best to temper your thoughts with as much background as possible. Perhaps it would help to have a discussion of what factors lead us dentists to suggest crowns, and what findings would sit on the fence between crown/no crown. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > That's really all I wanted to hear. What frosts patients (me at least > ), is when overtreatment is defended by dentists ( good,bad, and ugly [quoted text clipped - 7 lines] > > Jeff >I am doing my best to temper your thoughts with as much background as >possible. Perhaps it would help to have a discussion of what factors lead >us dentists to suggest crowns, and what findings would sit on the fence >between crown/no crown. Appoggitura to my ears... -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com > >I am doing my best to temper your thoughts with as much background as > >possible. Perhaps it would help to have a discussion of what factors lead [quoted text clipped - 4 lines] > >~+--~+--~+--~+--~+-- > >Stephen [What's a Temporary?], D.D.S. > Appoggitura to my ears... > -- > > W_B So YOU'RE the kid who won the spelling bee! I didn't even recognize you from the picture on the news. How'd you get to be a dentist so young? :-) - dentaldoc Of absolutely no relevance appoggatura is spelled appoggiatura. > That should be the biggest worry would be cause for celebration. Gail > > So YOU'RE the kid who won the spelling bee! I didn't even recognize you > from the picture on the news. > > How'd you get to be a dentist so young? :-) > > - dentaldoc Ok, fair enough. However, in an earlier reply I indicated that the dentists in question only agreed on one tooth. To be specific: Dentist A: #2 Crown #18 Crown #19 Crown #30 Crown #31 Crown Dentist B: #3 Filling 3 surface #4 Filling 3 surface #18 Crown Please tell me what I or anyone else, is to make of that. This is science? Ok, maybe their keeping mental notes on what can wait. IMO , that's wrong, any issues they're aware of should be clearly made known to the patient. Now I am going put dentist B on the spot( I just recieved his faxed report yesterday). He may not like it, but I will get an explanation to my satisfaction. "I But, the difference between 5 crowns and one crown plus 4 big fillings is tiny. the difference between 5 crowns and one crown plus two tiny fillings is huge. The difference between 5 crowns, and one crown now, 2 large fillings now, and mentally watching 2-3 other teeth to see if they show signs of stress or cracking is tiny. " Jeff >Ok, fair enough. However, in an earlier reply I indicated that the >dentists in question only agreed on one tooth. To be specific: [quoted text clipped - 28 lines] > >Jeff You either have dentist A who is overtreating, dentist B who is undertreating, or some combination of these two, maybe the first and last dentist under treat. Post photos of the x-ray images to a web page and let us see what is being discussed. There is a good chance dentist A is over treating, but maybe not. .. Stephen Mancuso, D.D.S. Troy, Michigan, USA I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. Wow, that would be great if you could take a look. I will request a copy from Dr. B. on Monday ( they've left for the day ), and post when I've got them online. Jeff Just an update. Spoke with Dr. B's office, and they said that the x-ray in question was not of good quality. So, they want to do a set of bitewings when my wife comes in to get her crown done on the 18th. If the existing x-ray itsn't good for them, then it would be even less readable if I were to put a copy on the net I suppose. I'll request a copy of the bitewings after their taken, and post them then. The saga continues. Jeff That would be fine. Hopefully the new office is digital and they can give you a copy on floppy or CD or even email them to you. We do this all the time. I keep blank floppies in the PC at all times. IF a patient expresses the least bit of interest in the images or seems to be uncertain of my recommendation, I immediately copy the image to the disc and hand it to the patient. The data is theirs, the cost of floppies is zero since I have so many laying around, so why not? Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > Just an update. Spoke with Dr. B's office, and they said that the x-ray > in question was not of good quality. So, they want to do a set of [quoted text clipped - 5 lines] > > Jeff I hadn't thought to ask if they are digital, but would hope so. It would certainly give a clearer image if we don't have to go the copy/scan route. In any event I'll get something to post. Jeff >Ok, fair enough. However, in an earlier reply I indicated that the >dentists in question only agreed on one tooth. To be specific: [quoted text clipped - 12 lines] > >Please tell me what I or anyone else, is to make of that. Just get over it! Go with the option you prefer and forget it. I was with my dentist for a couple of years and she was "watching" a filling for ages.. she left and I found another denist who on the first visit, said he would like to refill that tooth. It's understandable. He didn't have any history to go on. If the differences had have been any greater than that I'd have walked and got another opinion. Use your common sense. Tom >Dentist B: >#3 Filling 3 surface [quoted text clipped - 3 lines] >Please tell me what I or anyone else, is to make of that. This is >science? The Art & Science of Operative Dentistry. I don't do 3 surface "fillings". A stronger restoration is required. Onlay or crown. -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com > That's really all I wanted to hear. What frosts patients (me at least > ), is when overtreatment is defended by dentists ( good,bad, and ugly [quoted text clipped - 7 lines] > > Jeff Unfortunately, in any one individual case, it is difficult to determine UNLESS the patient is examined. I can assure you that my treatment has been misinterpreted or misrepresented to other dentists. It really is tough to know what went on unless you have personally been there. It isn't really "circling the wagons" so much as an understanding from personal experience that the message isn't always coming through clearly. Steve SignatureCut the nonsense to reply Of course, no sane person would expect a diagnosis sight unseen. The issue is two dentists, two radically differing interpretations of a patients mouth and Xrays. Call it circling the wagon's or PC ( professional courtesy ). Your saying it doesn't exist. I would hope that PC toward the patient would be at least as high on the list, as PC regarding a fellow dentist. I wonder what the odds are on a dentist saying, "don't quote me, but based on my examination of your mouth and xrays, the guy you saw before was full of crap", or words to that effect. I'm really hoping that's what my wife's ( and maybe my ) new dentist will say. We will see. "Unfortunately, in any one individual case, it is difficult to determine UNLESS the patient is examined. I can assure you that my treatment has been misinterpreted or misrepresented to other dentists. It really is tough to know what went on unless you have personally been there. It isn't really "circling the wagons" so much as an understanding from personal experience that the message isn't always coming through clearly" Jeff > Of course, no sane person would expect a diagnosis sight unseen. The > issue is two dentists, two radically differing interpretations of a [quoted text clipped - 6 lines] > effect. I'm really hoping that's what my wife's ( and maybe my ) new > dentist will say. We will see. I have seen poor dentistry, and have told patients it was poor dentistry. There are circumstances though that can vastly change the interpretation of WHY something was done a certain way. There is usually no way for an examining dentist to know these circumstances unless they are discussed beforehand. BTW, courtesy to the patient is a lot more involved (and more difficult) than slamming the old dentist. But believe me, I have no difficulty disagreeing with another dentist's prescribed treatment. Steve > "Unfortunately, in any one individual case, it is difficult to > determine [quoted text clipped - 8 lines] > > Jeff SignatureCut the nonsense to reply > ...As Dr. Steve M implies, this is an art as well as a science. ... Art? Yes. Science? Yes! But also it is a business. Vaughn >>...As Dr. Steve M implies, this is an art as well as a science. ... > > Art? Yes. Science? Yes! But also it is a business. > > Vaughn Tastes great--less filling! Certs is a candy mint--Certs is a breath mint! Gentle on hands? You're soaking in it! Manly yes--but I like it too! Steve SignatureCut the nonsense to reply Brilliant!! Fawks > Tastes great--less filling! > Certs is a candy mint--Certs is a breath mint! > Gentle on hands? You're soaking in it! > Manly yes--but I like it too! > > Steve Art? Yes. Science? Yes! But also it is a business. > Vaughn Skill Intelligence Ethics Compassion Just a few broad categories of what it takes to be a 'good' dentist. If any one area is lacking, major problems can easily develop. Where do you find someone with adequate skill, intelligence, ethics, and compassion to be the ideal dentist? Good question. It's also hard to find policemen, priests, lawyers, physicians, bankers, or just about any other professional that lives up to their ideals either. That makes it tough to tell when one dentists recommends 6 crowns because he is pretty sure the teeth are going to start falling apart in the next few years or if he is just seeing how much work he can diagnose to help production. If he does diagnose 6 crowns, can he deliver 6 excellent restorations? Does he have the knowledge to know when a tooth needs one particular restoration over another (or treatment at all) in the first place? Does he even care if you have teeth in five years anyway? Of course none of this explains the problems that arise when another person is involved in the issue (the patient). Ever wonder how society functions at all? ;-) Fawks It wouldn't be such a big issue about overtreatment if so much money were not at stake. I have seriously considered taking a "dental vacation" to a place where dentristy is less expensive. Over in Europe it is not uncommon for people to travel to Eastern Europe to get the work done. posted at www.healthcareforums.org > It wouldn't be such a big issue about overtreatment if so much money > were not at stake. I have seriously considered taking a "dental > vacation" to a place where dentristy is less expensive. Over in > Europe it is not uncommon for people to travel to Eastern Europe to > get the work done. > posted at www.healthcareforums.org How much eastern European dentistry have you seen? Steve SignatureCut the nonsense to reply >> It wouldn't be such a big issue about overtreatment if so much money >> were not at stake. I have seriously considered taking a "dental [quoted text clipped - 6 lines] > >Steve Have seen a fair bit... Blechhhh... -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com I have had, as students, scores of Eastern-European-trained dentists. It's not their fault - it's resources ($), culture, the once-upon-a-time Iron Curtain, other factors(?) - but, by American/Canadian/Scandanavian standards: they suck. As clinicians, that is. As people they're great, and happily most of them leave the postdoctoral programs as pretty good dentists. > I have had, as students, scores of Eastern-European-trained dentists. > [quoted text clipped - 4 lines] > As clinicians, that is. As people they're great, and happily most of them > leave the postdoctoral programs as pretty good dentists. Just to be clear--no slam on the dentists. I was talking about the actual standard of dental care in eastern Europe. Steve SignatureCut the nonsense to reply |
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