The great white hype, or the no-silver image?

You be the judge! Two well-known lecturers debate the trend toward no-amalgam practices. The remaining nine `rounds` of arguments will appear in the May and June issues.

You be the judge! Two well-known lecturers debate the trend toward no-amalgam practices. The remaining nine `rounds` of arguments will appear in the May and June issues.

Joe Steven Jr., DDS

William G. Dickerson, DDS, FAACD

Joe Steven Jr., DDS Opening remarks

Not a day goes by that I don`t question the judgment of dentists who have discontinued the use of amalgam in their practices. Yes, you`re reading this correctly. I`m sure this comes as a surprise to hear someone advocating the use of such an "antiquated" and "ugly" restorative material. Dr. Mark Troilo and I, along with Dr. Rick Kushner, are the only seminar presenters I know of who dare to speak about doing amalgam restorations in their practices.

Most practice management lecturers make you feel terribly inferior, and give you no respect if you do amalgams. Mark and I sometimes feel like the Rodney Dangerfields of dentistry on the lecture circuit. Heck, Dr. Bill Dickerson even calls me "Mr. Amalgam." But, I readily correct him and tell him that`s "Dr. Amalgam." At Dr. Woody Oakes` Spring Break Seminar in Destin, Fla., in March 1998, Mark and I did our presentation the day after Bill did his. During our meeting, we had fun with Bill and presented him with a certificate to attend the "Wichita Institute for Amalgam Restorations," so that he could learn how to do them properly. Then, he wouldn`t be limited to just doing white fillings. We`re still waiting, Bill!

I certainly am not interested in making enemies with any of the speakers who are telling dentists to quit doing amalgam restorations. But, if you do get a little perturbed with this perspective, let`s call it even. You have belittled me and all other well-meaning quality dentists over the past five years. You have called us stupid, unethical, uneducated, nonquality-oriented, unprofessional, and inferior. You have done more to tear down the self-esteem of honest, hard-working dentists than any dental school instructor could ever do.

The all too common seminar mantra we currently hear from virtually every speaker is the same: Throw away all of your amalgam and quit doing black fillings that patients don`t want. I truly believe that this is misleading advice to give to our profession. This advice results in a serious disservice to the majority of dentists and their patients.

Before I get too far into this, please let me set the record straight. I believe these leaders in our profession are providing a great service to dentists and patients by pioneering and educating us about new technological advancements. Our profession owes them deeply.

My only problem is that there is too much hype that unfortunately does not serve our profession well. All I would ask them to do with their presentations and writings is to recommend that dentists learn the new revolutionary techniques and incorporate them into their current practice, and then decide if they want to limit their practice to an amalgam-free one. I do believe it is wrong for them to advise all dentists to exclude amalgam from their practice.

I can`t say it any better than Dr. Rick Kushner did in his Simple Truth Newsletter: "How do you justify it? What is the ethical explanation? How do you defend it? What is the moral defense of denying patients the most economical, durable, serviceable, comfortable, time-tested, and safe restoration known to modern science? You don`t know what I`m talking about? Amalgam!" It`s time for more of us to speak out in defense of this valuable service that should be available to all patients. Let the patients decide.

I do believe every dentist needs to learn how to provide these valuable services and make them available to their patients. But, I also believe that most dentists need to have amalgam available for those patients who want it. I have no problem with dentists who want to limit their practice to only doing cosmetic restorations. But I do think it is wrong to advocate that all dentists should do this and then make them feel inferior if they don`t.

William G. Dickerson, DDS, FAACD Opening remarks

Editor`s note: Dr. Dickerson writes the article below as a direct response to Dr. Joe Steven`s article. It was submitted in the form of a letter - complete with a "Dear Joe" salutation and a "Sincerely, Bill" farewell. Obviously, "you" in every instance used refers to Dr. Steven - not necessarily all pro-amalgam supporters.

Against the advice of those who told me not to waste my time, I am responding to the article by you. I feel compelled to do so - not because I want to convince you of anything - but because I think your article does a great disservice to our profession that I love and hold so dear. You also slander and libel honest and decent people for their passionate beliefs. You are certainly entitled to your beliefs, but you have no right to make the claims against so many dentists that care so much about their message. For those reasons and those reasons alone, I feel compelled to respond to your erroneous and misguided article.

First, you claim that I (and others) have "done more to tear down the self-esteem of more dentists than any dental school instructor could ever do." In every one of my lectures, I go on a passionate rampage about the dentist being so valuable to society. It is my mission to make dentists understand how important they are to the public and to build their self-esteem. I have received hundreds of letters and many comments from dentists who thanked me for making them feel good about what they do for a living. Up to this point, I have never received a letter that said I lowered someone`s self-esteem. Perhaps you are speaking personally. If I ever made you feel that way, then I apologize. But you certainly can`t speak for anyone else.

You also claim that we tell everyone to stop doing amalgams. How can this be when only 20 percent of the practicing dentists go to continuing education programs? I have not even been able to reach all of that 20 percent. And why is it wrong to tell those who came to hear our opinion on dentistry exactly that, our opinion on dentistry? Wouldn`t they be disappointed if they came to hear me and I told them your opinion? I believe so, because I obviously couldn`t speak passionately about it. Should someone who believes passionately in pro-life counter his or her own speech with a pro-choice view? If I passionately believe in not doing amalgams, how can you ask me to stop saying that? I`m not asking you to say what you don`t believe. You make the statement that it`s OK to be a cosmetic-oriented practice, but then proceed to make statements like, "How do you sleep at night?" That doesn`t sound too understanding, now does it? You have never heard me ask pro-amalgam dentists how they sleep at night.

But the premise of your entire article is flawed. You base it on an erroneous statement and use an unscientific publication as your reference. You claim that amalgam is "the most durable, serviceable, comfortable, safe restoration known to modern science." Unfortunately, this flies in the face of the truth. The literature clearly shows that this is wrong. You cite the ADA as a source of the short life span of a crown. But you ignore that, according to the ADA, the amalgam has a shorter life span. You make the claim that you guys are the only speakers out there who do amalgams. Did you ever wonder why? Did it ever occur to you that you might be wrong, not everyone else?

Round #1

Steven`s Point

It`s all about money! Ten years ago, the main concern for dentists was the "busyness" problem. Dentists needed more business. Sure enough, seminar leaders found the solution: cosmetic dentistry. You make more money per procedure, and you don`t need as many patients, since these procedures take longer to do and are more expensive. Plus, look how many silver fillings need to be replaced!

This new philosophy was the ultimate dental nirvana. Problem solved! I don`t think I have seen as much rationalization about anything in our profession as I have seen with this issue. Dentists tend to believe everything that is being espoused by too many speakers.

Do you think that this trend would have taken off if this new revolutionary restorative technique had been something other than what we have today? Let`s imagine that this new restoration is simpler to place than amalgam. Let`s say the material costs less than amalgam, and it lasts longer than amalgam. And guess what? Because of all that, you could lower the fees of these restorations to your patients.

If this had come about, do you think that seminar speakers would obsessively preach about using this new technique in your practice in the name of quality? Absolutely not! There`s no money in it! Most dentists aren`t interested in learning new procedures that will decrease their production. But if you give them a new procedure that can be very profitable, it`s easier to believe what you want to about quality dentistry.

The best way to launch a career in lecturing is to gain prominence by advocating an amalgam-free practice. It just makes the speaker look more credible and on the "cutting edge." That`s why every new speaker on the circuit recommends throwing away your amalgam. Just because they found success with this philosophy doesn`t mean it is right for all dentists.

Key Point: If you give dentists a new procedure that can be very profitable, it`s easier to believe what you want to about quality dentistry.

Dickerson`s Counterpoint

This one is purely libelous. You claim that, "It`s all about money!" You sound like the White House and their spin-doctors. If you don`t have the facts, then maliciously attack. The White House claims those who voted for impeachment are part of a right-wing conspiracy. The vast majority of those who voted for impeachment did so because they honestly felt that perjury and obstruction of justice are impeachable offenses. They went against the popular view, at their own political risk, because they believed it was the right thing to do.

I also believe that the reason most lecturers don`t do amalgams is that they honestly don`t feel it is a worthy restoration. It has nothing to do with the cost. If it was all about money, I would still do amalgam restorations but I would charge a much higher fee. The cost of amalgams is set by us - not dictated to us. Those of us who are anti-amalgam know we are going against the popular view. But we believe it is the right thing to do. I know that I personally would never (and I do mean never) place an amalgam in the mouths of anyone in my family - or anyone I care about for that matter.

If I believe that passionately about it, how could I suggest to others that it is OK for their families? Why are you the only one entitled to a passionate feeling about this? But the worst thing about this claim is that you perpetuate the myth that has hurt the profession for so many years. The myth is that there is something wrong with making a living in a health-care profession such as dentistry. It is this myth that has destroyed our profession and is sacrificing the care the public receives. You cannot provide excellence unless you charge for it.

Perpetuating this view is a terrible disservice to dentistry. It has nothing to do with the amalgam issue. In fact, I tell everyone that, if you want to continue to do amalgams, you should triple the fee, as you are giving this service away.

Key Point: If it was all about money, I would still do amalgam restorations, but I would charge a much higher fee.

If you agree with Dr. Steven`s argument, circle 4 on the Reader Service Card. If you agree with Dr. Dickerson, circle 5. If it`s a "draw," circle 6.

Round #2

Steven`s Point

Is the advice from all the Bondodontists to discontinue amalgam the best thing for the general public? Most dentists have a "bread and butter" type of practice like mine, and they work mainly on average people. Many times, some of these patients can`t even afford a silver filling and have to resort to an extraction. If all dentists were to heed the advice of Dr. Bondo, then who will take care of those people who can barely afford a silver filling?

I think we all agree that a stainless steel crown is really considered to be an inferior restoration compared to a cast crown. But don`t most dentists have these available as a last resort for those patients who can`t afford a good crown? Why shouldn`t we do the same with amalgams? Even if you believe that amalgam is inferior to composites, for whatever reasons, shouldn`t the patient at least have the choice?

Shouldn`t all general dentists have optional treatment choices for their patients? If not, then those dentists are limiting their practice to a cosmetic one. There is nothing wrong with that; it`s very similar to a speciality practice. But as with all specialties, we all can`t be specialists, and we shouldn`t be. There isn`t the demand for that. It`s comparable to a Chevy dealership changing to a Mercedes dealership; they all can`t do that. The next time you listen to another lecturer telling you to throw away your triturator, ask yourself if you are willing to limit your practice to a cosmetic one.

Key Point: Even if you believe that amalgam is inferior to composites, for whatever reasons, shouldn`t the patient at least have the choice?

Dickerson`s Counterpoint

This one is about what is best for the patient. You make a very troubling statement, however, in this perspective. You claim that you have removed teeth because the patient couldn`t even afford a silver filling. I would certainly argue that the vast majority of patients can, in fact, afford a silver filling when they spend much more than that on things they don`t really need.

The truth is, they don`t want it because, to them, it has no value. This, of course, is our fault, since we have not properly educated patients about the value of keeping their teeth. But what is troubling is that you would remove a tooth that doesn`t need to be removed. Is that the best thing for the patient? I think not. I admire dentists who stand by their principles and refuse to do such treatment when they know it`s the wrong thing to do.

But you claim that we need to give the patient a choice. The truth is, every patient has a choice. They don`t have to have the treatment done in that doctor`s office. My patients have the choice of going to another, cheaper dentist. No one is forcing them to have the treatment done in my office. Just as the car buyer has the choice when going into a Lexus dealership of not buying a Lexus. The Lexus dealer shouldn`t have to offer the buyer a Yugo, should he? But just as patients should have a choice, I also should have the choice of not having to place a restoration I find ethically reprehensible. And just like there will always be lower-value car dealerships, there also will always be dentists who charge less, offer volume dentistry, and do amalgams.

As I said before, the only ones we give advice to are those who come to us looking for our advice by attending our seminars. No one is forcing them to take that advice.

Key Point: The truth is, every patient has a choice. They don`t have to have the treatment done in that doctor`s office.

If you agree with Dr. Steven`s argument, circle 7 on the Reader Service Card. If you agree with Dr. Dickerson, circle 8. If it`s a "draw," circle 9.

Round #3

Steven`s Point

Many dentists have trouble developing a good practice. I`m not talking about a great practice; I mean just a fairly profitable one. Some dentists have trouble selling a basic quadrant of amalgams. Why should we assume that they will be able to sell restorations for 1.5 to eight times that amount?

For most dentists, it`s not as simple as telling your patients that you now are concerned about quality dentistry and that`s why you don`t do amalgams any more. I have visited with many dentists who say, "Well, I did what Dr. Bondo told me to do. I`m referring out 85 percent of my patients who don`t want my quality (read cosmetic) dentistry."

I then ask them how they`re doing as far as production numbers. The most common response I get is, "I`m still doing around $30,000 to $35,000 a month." So what`s your point? You just turned away 85 percent of your patients. What did you expect?

Yes, I realize that there are many cases where it does result in very profitable practices. We see them behind the lecture podiums all the time. Every new seminar speaker on the circuit has the same similar story. But with the majority of dentists, this is not the case.

Dickerson`s Counterpoint

You say that you have visited with many dentists who claim they stopped doing amalgams, refer out 85 percent of their patients and still only make $30,000 to $35,000 a month. I personally have never known anyone who lost 85 percent of his patients.

But I have only one comment for that rebuke: Thank you! You just made my case. These doctors stopped the assembly-line practice, work fewer hours, see 85 percent fewer patients, have the time to spend with their patients, enjoy what they do for a living much more (placing beautiful quality restorations), and didn`t lose one dime in the process.

In every seminar, I ask those in the audience who no longer do amalgams to raise their hands. Then I ask them how many experienced a loss of income when they stopped. Only one hand has gone up in all these years, and that`s because he charged the same for esthetic restorations as he did for amalgams. In fact, when asked the next question about how many had their incomes increase, around 85 percent raise their hand.

Oh, but I forgot. It`s a crime to make money in dentistry. We all should be ashamed!

If you agree with Dr. Steven`s argument, circle 10 on the Reader Service Card. If you agree with Dr. Dickerson, circle 11. If it`s a "draw," circle 12.

Round #4

Steven`s Point

In the first 10 years of my practice, a common dental cocktail conversation usually included stories about how many dentists can`t even place a good amalgam restoration. Come on, we`ve all seen and criticized other dentists` amalgams: overhangs, open contacts, thumbprint anatomy, etc. Now, can you imagine what`s going to happen when all these dentists are turned loose with posterior composites?

Yes, yes, yes ... the key to doing these properly takes training, practice, and the commitment to extreme detail. In the real world of dentistry, you`re dreaming if you think it`s going to happen with the majority of dentists.

Key Point: My only problem is that there is too much hype ... I do believe it is wrong for them to advise all dentists to exclude amalgam.

Dickerson`s Opening Remarks

Key Point: Should someone who believes passionately in pro-life counter his or her own speech with a pro-choice view? If I passionately believe in not doing amalgams, how can you ask me to stop saying that?

If you agree with Dr. Steven`s argument, circle 1 on the Reader Service Card. If you agree with Dr. Dickerson, circle 2. If it`s a "draw," circle 3. "Rounds" five through 13 will appear in the May and June issues

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