Bite Point

Even Temporary Dental Treatments Should Be Beautiful

New patient. In pain from an infected root canal. Heat-Of-Battle situation, with limited time to solve her immediate problem, and our comprehensive whole-mouth diagnosis and treatment plan still in the future.

The temporary she came in with (and it was loose):

The provisional restoration I bonded in after eliminating the source of her pain:

Even temporary dental treatments should be beautiful.

(And to those in my field who assert things like, "Never make emergency treatments look too good, the patient won't come back," I say: Wrong. You're missing the point.)

Some Specific Permission Marketing Concepts in Dentistry

This, the third in a series of three posts, is for students, residents and young dentists. Anyone, of course, can read it and I hope it is useful to all.

(Note: This page is one I will edit and add to over time. Check back sometime and see if there's anything new.)

It's time to get down to brass tacks. Where did that expression come from, anyway? Let's review some of the specific Permission Marketing concepts and strategies we create and employ in our dental practice. We will review a number of things we do that surround the dentistry.

The Personal Interview

These days, many new patients fill out their registration information via our online form, so we already have much of their information long before they arrive in our office. Whether we have this or not, the personal interview is an essential part of our new patient experience.

We do not reach through a window and hand new patients a clipboard with the registration form on it. Our staff personally interview new patients and ask the demographic and other questions in a conversation, "eye-to-eye and knee-to-knee." In this manner, our staff and our new patients get into rapport with each other. We find out why a patient is here and what are their concerns for their oral and general health.  These conversations run all the way from "I'm fine; I just moved to Philly and I know I need a cleaning" all the way to people breaking down into tears because they're in pain or their appearance is suffering. And the personal interview is the first step we take in helping them.

Thus, a natural, informative, human conversation becomes the gateway into our practice.

Our Website

Our website is meant to inform and educate and connect with the patients we already serve. Who, if we respect them, listen, and provide excellence and certainty, may do us the honor of telling their family and friends about us. It is not designed to brag and show off and advertise.
http://www.smilephiladelphian.com/

My Blog

Advertising and bragging with a blog always seemed wrong to me. Unfortunately, that's what many dental blogs do.

Well. The Internet is the first communications medium in human history where everyone who has a receiver--also has a transmitter. Think about that for a moment. And then ask yourself the question that I asked myself when I started writing: "Ok now, we've been given this incredible gift--the ability to write in public, without having to ask anyone's permission. This gift is also a responsibility. What will I do with it?"

I write my blog to send anticipated, personal, relevant messages to patients who have a diagnosis or treatment plan that we discuss in the office. I write on a wide variety of dental topics. I approach the technical side, the human side and the business side of dentistry. Some of these posts end up being relevant to diagnoses and treatments that we do for patients. So, to round out their knowledge of the treatments or treatment decisions that they msut face, I send them links to relevant posts.

And I always end with, "Please feel free to email with any questions or concerns you may have; this one comes back to me." Thus becoming that rare species of doctor--the species that encourages patients to contact them when they have a quesiton.

The Caries Clock

Withthe help of some folks who are skiled at computer graphics, I created the "Caries Clock"-- the greatest patient educational tool ever when it comes to understanding and preventing cavities. Behavior is notoriously difficult to change; our Caries Clock gets people thinking about how they eat as well as what they eat (and drink). This is especially important in our sugar-laden culture. And, in the spirit of "Generous businesses are more interesting than selfish businesses," our Caries Clock is free and available for anyone with Internet access, from Philadelphia to Ulan Batur.

http://www.smilephiladelphian.com/clock/Caries.php

(Being a wav file, the Caries Clock may not work on phone and pad devices.)

The Surgical Operating Microscope

Microscope dentistry is defect-free dentistry. When I work through my Microscope (I always capitalize the word), I have six levels of magnification, all the way from seeing the entire arch of teeth in a jaw to seeing the inside of one tooth at such magnification that I can only observe; I can't even work at that level. It's amazing, each and every day I use it. I feel like I'm inside the tooth with a little miner's helmet on with a light, treating and cleansing everything from within. I perform every treatment better in the Microscope, and once or twice a week I do something that I couldn't even do without my Microscope.

The Sukoneck & Wilson Premier Plan

In an effort to help our patients who do not have dental insurance, we have designed an affordable alternative plan to maintain patients' dental health. This is not dental insurance, and is exclusive to our office. Our Premier Dental Savings Plan allows patients the opportunity to visit our office regularly for preventive dental care. In addition, all other dental treatment, if necessary, will be discounted by 20%. Patients who enroll in the plan simply pay 80% of our regularly posted fees. Preventive care, which includes regular cleanings and examinations, is essential for optimal dental health. This Plan is designed to help patients without dental insurance to make regular visits to our office.

http://www.smilephiladelphian.com/insurance.php

 

 

How Patients Choose a Dental Practice

This, the second in a series of three posts, is for students, residents and young dentists. Anyone, of course, can read it and I hope it is useful to all.

Oh, this post isn't going to explore everything about how patients decide which dental practice to visit for their care. I will explain one aspect of that decision process, though, and in great detail. In this post I explain why some patients choose a dental practice based on cost and why, for some patients, cost is not the only consideration.

You will learn why some patients go to corporate practices where everything and everyone is interchangeable, and why some patients seek care in private practice, from a dentist they know personally.

This post is for anyone, but I'm particularly writing for students of dentistry and young dentists. This is a follow-on to my post "A Message to Young Dentists."

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2014/01/a-message-to-young-dentists.html

Many dentists are somewhat fearful of corporate dental practice, partly because a corporate practice can supposedly provide dental care at a lower cost than private practice can. This is not quite so threatening as it seems at first glance. As we saw in our last post, there are many human factors that surround the dentistry itself. These factors include, but are not limited to: listening to patients; educating them about prevention; solving their problems (often in terms of physical pain or esthetic pain); and generally expending emotional labor to make a real connection with the human being in the chair.

Corporate dental practice is not interested in, equipped for, nor capable of providing these "soft innovations" for patients. By definition, corporations are legal instruments which are mandated to maximize profits for their shareholders. In dentistry, corporate practices "race to the bottom" on cost, and often strive to maximize profitability by means of over-diagnosis and over-treatment. Common examples include performing root canal treatment when a tooth could remain healthy with its vital pulp, or performing periodontal therapy on all new patients--whether they need it or not.

But corporate dental practice (supposedly) costs less to the patient. (When they claim that, I suppose they are not factoring in their over-diagnosis and aggresssive over-treatment.) This assertion generates important questions for we who are in private practice or small group practice. Do patients generally seek dental care based solely on cost considerations? How are we to compete with corporate dentistry if they do?

Insights into these questions are to be found in Diffusion of Innovations theory. 

Diffusion of Innovations theory seeks to explain how, over time, an idea, technology, product or behavior gains momentum and diffuses (or spreads) through a specific population, culture or social system. The definitive text is Diffusion of Innovations, Everett Rogers, 5th Edition (2003). Diffusion theory posits four main elements that influence the spread of a new idea: the innovation, communication channels, time, and a social system. There are five categories of adopters of innovations: Innovators, Early Adopters, Early Majority, Late Majority, and Laggards. Study after study of all sorts of innovations and all sizes of social systems show that categories of adopters can be recognized and defined. Further, these studies show that the successful spread of an innovation follows an S-shaped curve, with these adopter categories plotted against time. Here are the two curves combined into one graph:

Let's let Dr. Rogers himself explain a bit more about how this all works:

"The innovation-decision process is the process through which an individual (or other decision-making unit) passes from gaining initial knowledge of an innovation, to forming an attitude toward the innovation, to making a decision to adopt or reject, to implementation of the new idea, and to confirmation of this decision. This process consists of a series of choices and actions over time through which an individual or a system evaluates a new idea and decides whether or not to incorporate the innovation into ongoing practice. This behavior consists essentially of dealing with the uncertainty that is inherently involved in deciding about a new alternative to an idea previously in existence. The perceived newness of an innovation, and the uncertainty associated with this newness, is a distinctive aspect of innovation decision making (compared to other types of decision making)."

These remarkable concepts apply to every purchase you make, every project you start at work, every new technology you decide to adopt--they even apply to every person you date. For our purposes here, we can take "innovation" to mean "your dental practice," or any specific attribute within your dental practice.

Let's now present an overview of the main characteristics and values of each adopter category, which will be followed by more detailed generalizations. Here again is the Diffusion curve, followed by Dr. Roger's descriptions from his text of each adopter category.

Innovators: Venturesome

Venturesomeness is almost an obsession with innovators. Their interest in new ideas leads them out of a local circle of peer networks and into more cosmopolite social relationships. Communication patterns and friendships among a clique of innovators are common, even though these individuals may be quite geographically distanced. Being an innovator has several prerequisites. Control of substantial financial resources is helpful in absorbing the possible losses from an unprofitable innovation. The ability to understand and apply complex technical knowledge is also needed. The innovator must be able to cope with a high degree of uncertainty about an innovation at the time he or she adopts. The salient value of the innovator is venturesomeness, due to a desire for the rash, the daring, and the risky. The innovator must also be willing to accept an occasional setback when a new idea proves unsuccessful, as inevitably happens. While an innovator may not be respected by other members of a local system, the innovator plays an important role in the diffusion process: that of launching the new idea in the system by importing the innovation from outside of the system’s boundaries. Thus, the innovator plays a gatekeeping role in the flow of new ideas into a system.

Early Adopters: Respect

Early adopters are a more integrated part of the local social system than are innovators. Whereas innovators are cosmopolites, early adopters are localites. This adopter category, more than any other, has the highest degree of opinion leadership in most systems. Potential adopters look to early adopters for advice and information about an innovation. The early adopter is considered by many to be “the individual to check with” before adopting a new idea. This adopter category is generally sought by change agents as a local missionary for speeding the diffusion process. Because early adopters are not too far ahead of the average individual in innovativeness, they serve as a role model for many other members of a social system. Early adopters help trigger the critical mass when they adopt an innovation. The early adopter is respected by his or her peers, and is the embodiment of successful, discrete use of new ideas. The early adopter knows that to continue to earn this esteem of colleagues and to maintain a central position in the communication networks of the system, he or she must make judicious innovation-decisions. The early adopter decreases uncertainty about a new idea by adopting it, and then conveying a subjective evaluation of the innovation to near peers through interpersonal networks. In one sense, early adopters put their stamp of approval on a new idea by adopting it.

Early Majority: Deliberate

The early majority adopt new ideas just before the average member of a system. The early majority interact frequently with their peers but seldom hold positions of opinion leadership in a system. The early majority’s unique location between the very early and the relatively late to adopt makes them an important link in the diffusion process. They provide interconnectedness in the system’s interpersonal networks. The early majority are one of the most numerous adopter categories, making up one third of all members of a system. The early majority may deliberate for some time before completely adopting a new idea. Their innovation-decision period is relatively longer than that of the innovators and the early adopters (see Chapter5). “Be not the first by which the new is tried, nor the last to lay the old aside,” quoted at the beginning of this chapter, particularly fits the thinking of the early majority. They follow with deliberate willingness in adopting innovations but seldom lead.

Late Majority: Skeptical

The late majority adopt new ideas just after the average member of a system. Like the early majority, the late majority make up one third of the members of a system. Adoption may be both an economic necessity for the late majority and the result of increasing peer pressures. Innovations are approached with a skeptical and cautious air, and the late majority do not adopt until most others in their system have already done so. The weight of system norms must definitely favor an innovation before the late majority are convinced to adopt. The pressure of peers is necessary to motivate adoption. Their relatively scarce resources mean that most of the uncertainty about a new idea must be removed before the late majority feel that it is safe to adopt.

Laggards: Traditional

Laggards are the last in a social system to adopt an innovation. They possess almost no opinion leadership. Laggards are the most localite of all adopter categories in their outlook. Many are near isolates in the social networks of their system. The point of reference for the laggard is the past. Decisions are often made in terms of what has been done previously, and these individuals interact primarily with others who also have relatively traditional values. Laggards tend to be suspicious of innovations and of change agents. Their innovation-decision process is relatively lengthy, with adoption and use lagging far behind awareness-knowledge of a new idea. Resistance to innovations on the part of laggards may be entirely rational from the laggards’ viewpoint, as their resources are limited and they must be certain that a new idea will not fail before they can adopt. The laggard’s precarious economic position forces the individual to be extremely cautious in adopting innovations. “Laggard” might sound like a bad name. This title of the adopter category carries an invidious distinction (in much the same way that “lower class” is a negative nomenclature). Laggard is a bad name because most nonlaggards have a strong pro-innovation bias. Diffusion scholars who use adopter categories in their research do not mean any particular disrespect by the term “laggard.” Indeed, if they used any other term instead of laggards, such as “late adopters,” it would soon have a similar negative connotation. But it is a mistake to imply that laggards are somehow at fault for being relatively late to adopt. System-blame may more accurately describe the reality of the laggards’ situation.

*****

Me again. Please understand that we all have moments and phases in our lives where we act in each adopter category. For instance, back in the day I resisted buying a CD player for as long as possible. Then, I still bought CDs for a bit when online streaming of music became the delivery method of choice. Yet I practice dentistry with a surgical operating Microscope, and have an incredible array of high-tech equipment in the office. I drive a hybrid car and have two electric lawn mowers--one of which is a robot.

The point is, even though we all have Laggard as well as Early Adopter moments in our lives, each of us has a primary tendency which correlates to our risk tolerance and the size and heterogeneity of our social systems. We thus can simplify and use the above definitions of adopter categories for the purposes of this discussion.

The reason I wanted to introduce these Diffusion concepts to you is so that you can understand my assertions:

Laggards, Late Majority and some of the Early Majority tend to be highly sensitive to pricing, and tend to choose corporate dental practices. They tend to rank cost factors higher than interpersonal factors. These "soft" or interpersonal factors include personal connection to the doctor and staff, as well as other factors like thorough diagnosis, detailed explanations of treatment, practicing conservative treatment, and being listened to.

Innovators, Early Adopters and some of the Early Majority tend to be highly sensitive to interpersonal factors, and tend to choose private or small group dental practices. They tend to rank interpersonal factors higher than cost factors.

There are always exceptions. As I look back through practice, I can recall Innovators and Early Adopters who left our practice when some lower-cost alterative became available. I can also recall Laggards who have happily visited us for years and years, and would never turn to an anonymous corporate dental experience. By and large, however, the above tendencies appear to me to hold true. Always one to turn to hard science for answers to tough quesitons, I would like to see this question studied by qualified Diffusion scholars.

We now have an important part of the answer to the question, "Why do some patients choose a dentist purely based on cost considerations?" We also can answer the question, "Is corporate dentistry going to put me out of business?"

The answer is no.

Again, as I asserted in my previous post, many modern consumers are looking for Certainty, and also for simple, basic human Connection. They want to be delighted, and they want their problems solved. Consumers are highly connected, informed and they know how to cut through the clutter to find what they want. Lastly, consumers are sick and tired of being interrupted. As the marketers in the world respond to being ignored by yelling ever louder at us, we turn away with ears that become ever less attuned to the cacaphony going on around us.

Thus, many Innovators, Early Adopters and Early Majority are seeking out business experiences where they find Connection, Certainty, sustained trust, respect and good listening. These are things that corporate dental practice is neither inclined to, nor capable of, providing.

After all this detail, you deserve some brevity. I can sum the whole thing up in eight words: "Listen to your patients, and you shall prosper."

We have one more issue to deal with: Interruption Advertising versus Permission Marketing.

Interruption Advertising means, ah, let me just say it simply: interrupting us with ads. The thing is, nowadays we are interrupted by advertising messages in all media and in every place and time marketers, in their near-infinite deviousness, can place them in. We're watching the game and--!bam!--interrupted by an ad. Reading a dental journal? !Bam! Interrupted by an ad, and we have to pause and turn the page and re-start our reading. (In a more genteel age they put them all at the back!) Need to gas up our car? !Bam! Interrupted by an ad, right there on the pump. Often these days, gas pumps have more than pictures. They have video and blaring sound. Buses, billboards, online banners...now they're even talking about ads on the grounds of public schools.

Permission Marketing, on the other hand, as defined by Seth Godin is: "The privilege (not the right) of delivering anticipated, personal and relevant messages to people who actually want to get them."

http://sethgodin.typepad.com/seths_blog/2008/01/permission-mark.html

I have two more assertions for you, and they are summed up in this image:

My assertions are:

Innovators, Early Adopters and some of the Early Majority tend to be influenced by messages delivered by Permission Marketing.

Laggards, Late Majority and some of the Early Majority tend to be influenced by messages delivered by Interruption Advertising.

I'll leave you with a final thought. When we market our dental practice, we don't need to try to reach Everyone. That's too expensive, and to reach Everyone we would need to water down our message too much. Weaken what we stand for. Average ourselves out. Sand off all our edges--all our edges that are interesting.

We need to reach Opinion Leaders. These are folks with the ability to influence, informally, other's attitudes or behavior. Opinion Leadership is earned and maintained. It's not a sure thing. And Opinion Leaders tend to reside in the Early Adopter and Early Majority categories. Not so much the Innovator category--often, Innovators lie outside the norms of their social system, and they're too quirky in their venturesomeness to have direct influence over the majority. Rather, Innovators exert their profound influence on their social system through the Early Adopters who try their ideas and talk about them to all who will listen.

If we use Permission Marketing to spread awareness of our dental practice and what we do for our patients, we can be efficient with our efforts. We don't have to spread out a vast marketing funnel in hopes that some tiny fraction of the people who see the message will actually appoint in our office. We need only reach Opinion Leaders--and knock their socks off with delight and problem-solving, and they will become megaphones for us.

http://sethgodin.typepad.com/seths_blog/files/flippingfunnelPRO.pdf

I would also like to see these two assertions given proper scientific study by a Diffusion scholar. Meantime, I am utterly convinced that they are true.

As you grow your practice, consider employing Permission Marketing and minimizing your expensive Interruption Advertising efforts. (It's still a good idea to have a little bit of it in your marketing mix.) One other advantage of Permission Marketing: it's more congruent with who you really are.

Now why would I say that?

Most advertisements present an idealized version of the product or service that they’re attempting to make us aware of. They promise glitz and glamour where the product is only dross. Romance when the customer is only going to be let down by the banal. Powerful experiences where there is really no experience at all, only a commodity. The truth is, the best marketing is not an advertisement at all, but rather a remarkable product or service.

*****

Next post we will discuss specific Permission Marketing steps you can take in your dental practice that lead to success.

A Message to Young Dentists

A message to young dentists.

This, the first in a series of three posts, is for students, residents and young dentists. Anyone, of course, can read it and I hope it is useful to all.

I've hit a point in my career where I'm concerned more than ever before about the stewardship of our dental profession. You see, I've never been more proud of my colleagues who are serving their patients and making a difference in their communities. At the same time, there are dentists who are only concerned with the selfish pursuit of More, with a capital "M." More money, more new patients, less costs... Corporate dental practice is especially mired in a “race to the bottom” on cost. Corporations are legal instruments designed to maximize profits for their shareholders. That’s fine to an extent, but in dentistry they start doing inappropriate things to maximize profits and cut costs. Corporate practices push their employees to over-diagnose and over-treat. “Every new patient needs periodontal treatment regardless of their actual diagnosis” is one all-too-common example of how they operate. Starting root canal treatment when a well-bonded composite resin restoration would do just fine to keep a tooth healthy is another corporate tactic. And yet there are also solo practitioners who take more than one page from the corporate playbook and practice in the same manner. Further, many consultants and practice management gurus are running around teaching dentists to be selfish, compounding the problem of focus on More.

I’m afraid that students, residents and young dentists look at all this bottom-line, lowest-common-denominator selfishness and get to feeling like a they're just a cog in a vast machine. And nothing could be further from the truth. There’s a powerful way for you to stand on your own and fight the race to the bottom, which is technically referred to as Bertrand Competition.

Do you know Bertrand Competition?
http://en.wikipedia.org/wiki/Bertrand_competition

It's an oversimplification, but a useful one because it shows us the mistakes we might easily make. Essentially, Bertrand postulated that for goods and services with a geographic limitation—like dentistry as opposed to online sales—given two or more equivalent products or services, consumers would overwhelmingly choose the one with the lowest cost. Thus, each competing business races to the bottom on cost until one is offering the good or service at just above the marginal cost of production. The profit margin becomes tiny and the business "makes it up in volume." In dentistry, this is what corporate practices do, and perhaps to an extent it is what large group practices tend to do.

Well, the problem with a race to the bottom is that you might win. It’s not a pretty place to be.

Further, the problem with applying the Bertrand assumption to your own future in dentistry is: YOU ARE NOT EQUIVALENT!

You are Unique. Remarkable. Bespoke.

If I could get every recent grad to believe this, I would set you on a course of changing our profession.

I understand your fear. But what you fear is actually the most powerful lever you’ve got. Let’s break it down.

We now live in a world where it's almost impossible to buy attention. Consumers are smarter, more connected and more self-involved than ever, and they've gotten masterful at ignoring interruption advertising. The response of marketers has been predictable: the less we pay attention to their interruptions, the more they interrupt us. That means they yell louder at us in a desperate attempt to be paid attention to. And of course we ignore that, and so they yell even louder in a vicious feedback loop. The upshot is that interruption advertising is now so loud and pervasive in our culture that we dentists have no chance to cut through the clutter. Even if we could make it work, the cost is prohibitive. (Think of those few dentists or corporate practices that advertise on a massive scale. Perhaps you've seen their messages at sports arenas and on billboards or radio. Think of the expense of such an ad and the sort of patients it may attract, and ask yourself what it would truly cost you to do such a thing. Especially, what it would cost you in non-monetary terms.)

Turning to the consumer/patient side of the issue, then—How can we reach these folks who need us?

Hint: that’s actually the same question as—What do they want from us?

Our patients crave Certainty, and they desire simple human Connection. They rarely find Certainty and Connection in their experiences with corporations or (gasp) the government, so there’s a tremendous opportunity for us if we provide these scarce things for them. Scarcity is always valuable.

I agree with Seth Godin, and break it down this way:

1- Our patients want to be delighted. (Perhaps where they don't expect it. Perhaps they don't expect to be delighted in the dental office.)

2- Our patients want to have their problems solved. The more interesting the problem, the better. In dentistry, this tends to mean physical pain or esthetic pain.

Our most logical choice—our only choice—is to race to the top on the value of our services. That is long-term, strategic thinking. Racing to the bottom is short-term, profit-focused thinking. Many patients want a dentist who focuses on their problems and who delights them. The irony ends up being that more and more, the dentist who does not directly think about profits, but who thinks of their patient primarily—is the one who actually experiences the profits. There are notable exceptions, but nowadays many consumers are informed and connected (and selfish) and they figure out faster than ever when they are being taken advantage of. And they walk away from selfish businesses faster than they ever did before.

And so the irony and the existential paradox is that the path to More for us in dentistry is not to be selfish, as the consultants and practice management gurus would have us be. Idiots. The path to More is to be generous. To focus on our patients. To spend emotional labor in our practices. To listen.

Emotional labor is a concept we as a profession need to have a conversation about but to me it can be summed up in four simple words: "Caring and showing it."

Listening to patients, really listening, is the key to all this. Surprisingly, racing to the top does not involve all that much financial expense, once one has excellent equipment and technology in the office. Racing to the top involves emotional labor more than anything else.

To be generous, to actually listen to patients, to put total focus on solving their problems—that's interesting, and worthy of their attention. Always remember: Generous businesses are more interesting than selfish businesses.

My assertion is that each and every one of us who listens to our patients, solves their problems and races to the top on excellence of care will enjoy a long and prosperous career, and is making a vitally important contribution to the future of our dental profession.

*****

Next post we will discuss racing to the top (and bottom) from the patient's standpoint. Then we shall follow with a post on specific steps you can take in your dental practice that lead to success.

Crowns, Onlays and the Dental Pulp

Many things can cause harm to the dental pulp, which is the living tissue inside our teeth. This image from the excellent DDS GP app is helpful in visualizing the pulp and where it's located:

It's the deeper orange area inside. Harm can come to it by decay, trauma, gum disease and other factors. It's delicate tissue and it can die off and get infected when challenged by any of the problems I mentioned, and then infection and (usually) pain ensue. At that point, root canal treatment or extraction become the only ways we have to solve the infection and relieve the pain.

One of the responsibilities of a dentist is to be a steward of the health of the dental pulp. Every treatment we render, every procedure we perform must be done with consideration and respect for the consequences to this fragile, mysterious and often frustrating little component of human anatomy.

Often, a full crown restoration is necessary to properly restore a tooth. Situations like this, with a great deal of missing tooth and fracture lines in the inner dentin, are ones where crowns are the only chance of saving a tooth and keeping it in function:

Onlays are different than crowns in that they don't go all the way down the sides of the tooth; they don't go to the gumline. Important: crowns and onlays both cover the entire top of a tooth--the occlusal surface. The difference is, crowns cover all sides down to the gumline, where onlays leave a great deal of the tooth alone. There are now modern ceramic onlays that take advantage of our advances in dental adhesion. They "stick" onto the tooth so well that the mechanical interlock and retention of older onlay designs and crowns can actually be left behind.

Some authors call these newer restorations "Flat-Surface Onlays with Locator Margin," which is the term I tend to use. Other authors, like Dr. Ed McLaren, call them "Vonlays," which is a portmanteau word that combines "Veneers" and "Onlays." Either way, the idea is that if the restoration was just totally flat we'd never be able to place it accurately--it would just slide around on the tooth. I used to prep a shallow groove all around the tooth which acts as the locator margin. At a recent course, Dr. Ray Bertollotti suggested an update which is to just bevel one side of the tooth. This innovation has been working out extremely well since I adopted it.

Here are some images of a ceramic crown and a ceramic flat-surface onlay for direct comparison, including a shot of just the preps. They are followed by an image of a cross-section of a porcelain-to-metal crown, which is really still the workhorse restoration for back teeth that have been extensively damaged by decay.

Now, back to the dental pulp--is there a difference between a crown and an onlay when it comes to the pulp? Absolutely. Consider these cross sections, again using DDS GP images, of the preps that are required to restore a tooth with a crown or an onlay. The heavy black line indicates a cross section of what tooth will remain after the prep. (Note that some of what remains may be bonded filling materials, as there are usually random patterns of damage to a tooth before these procedures are done to save it.)

Crown:


Flat-Surface Onlay:

Wow! We're a heck a lot farther away from the pulp with the onlay prep than with the crown prep. Consider that the inner dentin of a tooth has a lot of porous microscopic channels in it, and staying far from the pulp is even more appealing. In the end, root canal treatments are necessary because bacteria attack the pulp, and the pathway in is under the restoration and through the dentin. By leaving a lot of the tooth alone and staying farther from the pulp, flat-surface onlays better protect that pulp from bacterial attack. Also, flat-surface onlays are by defnintion bonded onto the tooth. That bond tends to provide a better bacterial-tight seal than the cements that are often used to place full crowns.

Finally, recent research is indicating that the germs that reside just under the gumline are particularly vicious. They are aggressive in their constant drive to find the best niche to live in and they keep trying to force their way into our teeth. Natural tooth structure is better at resisting them than crown margins are.

If we already have a root canal treatment in a tooth, we no longer need to worry about the pulp getting killed off. Still, re-infections of root canal treatments do occur, and it's worth considering the notion of leaving natural tooth structure at the gumline when possible. Thus, flat-surface onlays can be appropriate on root canal-treated teeth, as long as the tooth isn't too broken down by the original decay and fillings.

Here are before and after images of my favorite flat-surface onlay that I've ever done. This patient once had gum disease and has been rigorously maintained by an excellent periodontist for decades. The gum recession is severe though. When this tooth broke, crowning it would have entailed all kinds of problems. Since teeth taper and get narrower as we go up their roots, a crown surely would have killed the pulp, not to mention weakened the tooth so much that it would have snapped off at the gumline in time. With a flat-surface onlay, I was able to leave most of the tooth alone.

Do I still do full crowns for patients? You bet. But I always give consideration to modern direct composite resins and to flat-surface bonded onlays--for that means giving consideration to the fragile dental pulp.

 

Computer graphics provided by DDS GP http://www.ddsgp.com/DDSGP/Home.html