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 first five `rounds` of debate appeared in the April issue; the debate concludes in the June issue.

You be the judge! Two well-known lecturers debate the trend toward no-amalgam practices. The first five `rounds` of debate appeared in the April issue; the debate concludes in the June issue.

Joe Steven Jr., DDS

William G. Dickerson, DDS, FAACD

Round #5

Steven`s Point

When a dentist lectures to me about quality dentistry, I usually say, "Oh, so you`re doing a lot of gold inlays and onlays?" Too many of our gurus are interpreting "cosmetics" as "quality." I think if you were to survey patients, quality to them would be something that doesn`t hurt and lasts a long time.

My mouth has been restored with gold inlays and onlays 22 years ago in dental school. Guess what? They`re still there! Can any of us really expect that these cosmetic restorations will last that long?

My father-in-law passed away several years ago with eight MODBL pin-retained amalgams that were placed before I became a dentist. I kept an eye on them every six months. I constantly planted the seed that, one of these days, we would need to place crowns when these teeth started to break down.

Many dentists would have crowned those eight teeth years ago. I read an ADA statistic that stated that the average life expectancy for a crown is only seven years. I think that`s a very low estimate. But regardless, if crowns had been placed to begin with, my father-in-law would have gone through at least two crowns on each of those teeth. Conservative, traditional treatment saved him needless inconvenience, and expense.

I can`t believe I`m setting myself up for the abuse I`m about to take on this one. But, I have to share with you what I think is a very good service. The common complaint that the Bondodontists have about amalgam is that it fractures off cusps. When doing an amalgam on a weak cusp, I used to (and occasionally still do) cap the cusp with amalgam. Every day, I continue to see those that I placed 15 years ago and they`re doing great. That`s one or two more crowns I saved that patient.

Dickerson`s Counterpoint

You were right when you said, "I can`t believe I`m setting myself up for the abuse I`m about to take on this one." You claim that your father-in-law died (and I`m sorry about that) with 14-year-old amalgams in his mouth that you told him needed to be replaced. Somehow, according to you, that justifies leaving them in. Did you remove them afterwards to see how much decay was under them? What does this have to do with anything? You claim that it was better than a crown, since the ADA says the average life expectancy for a crown is only seven years. But what you failed to mention is the average life expectancy for an amalgam, which is less than that.

You also claim that when you do an amalgam and the cusp is weak, you cap the cusp with amalgam. I challenge you to show me any scientific literature by a respected clinician that says this is an acceptable treatment. Again, is this the best thing for your patients? The scientific literature, which I will send you if you promise to read it, clearly states that the expansion properties of the amalgam restorations have a deleterious effect on tooth structure. Yes, we all can find amalgam that has lasted a long time, but statistically, that is the exception, not the rule.

Key Point: The scientific literature... clearly states that the expansion properties of amalgam restorations have a deleterious effect on the tooth structure.

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.

Round #6

Steven`s Point

Don`t we have any fiscal responsibility in trying to keep the cost of medicine down? Americans spend $42 billion a year for dental care. If all dentists were to adapt to this new trend, this figure easily would double, if not triple.

Instead of a posterior amalgam for $70, the patient would pay anywhere from $100 for a direct composite to $300 to $500 or more for an indirect Concept or Empress. In a few years, the cost will go up even higher when dentists start replacing all of those restorations that weren`t placed properly - which will probably be the majority of them!

Key Point: Don`t we have any fiscal responsibility in trying to keep the cost of medicine down? Americans spend $42 billion a year for dental care.

Dickerson`s Counterpoint

You claim, "Don`t we have any fiscal responsibility in trying to keep the cost of medicine down?" There you go again, perpetuating the guilt that dentists have for adequately charging for their work. You also are playing right into the hands of the insurance companies. For this one, you ought to be ashamed.

It is this guilt that has stifled the growth of dentistry and has contributed to our great profession`s downfall and the emergence of managed care. Ignore the fact that dentists` incomes have not kept up with inflation in 23 out of the last 25 years. Ignore the fact that seven dental schools have closed because the best and brightest are no longer choosing dentistry. Ignore the fact that only one-third as many college kids want to be a dentist today as compared to when I wanted to be a dentist.

What you are doing is contributing to that low self-esteem and self-worth that you so maliciously claimed we were doing to the average dentist.

You state that Americans spend $42 billion a year on dental care, as if we should be ashamed. Yes, to the average dentist reading this, that sounds like a lot of money - until they find out that billions more are spent on dog food and tobacco. More than twice that much is spent on women`s hair care products. More than twice that is spent at one store, Wal-Mart. Women spend more that twice that ($100 billion) on cosmetic surgery; liposuction alone accounts for more than what was spent on dentistry. Billions more were spent on alcohol. Americans spend $300 billion on gambling!

Kind of makes dentistry look like a bargain, doesn`t it? Stop making dentists feel guilty about charging a fair price for what they do. We are very important and certainly more important than any of those items listed above.

Key Point: Americans spend $300 billion on gambling! Kind of makes dentistry look like a bargain, doesn`t it?

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 #7

Steven`s Point

I visit with doctors all the time about their non-amalgam experiences. I`m shocked at some of the things I hear. I usually ask if there is ever a time when they wished they had amalgam available. They usually reply, "Yes," especially if it`s a subgingival Class V on a molar or a deep gingival box on a Class II. Then they go ahead and place the composite, informing the patient that they will need to have a crown placed on it within a few months. Or, they just go ahead and do the crown.

Is this called good dentistry, when you know that a facial amalgam would probably last 20 years and cost one-tenth the cost of a crown (that, more than likely, will not last that long)? How can you tell a single mother of four children that you do not provide this service and still sleep at night? Unless, of course, you have made the decision to limit your practice to a cosmetic practice which caters to a limited source of patients who can afford these services.

I recently did an Empress onlay and an inlay on a hygienist, because she really wanted them. During the entire procedure, I truly was perplexed as to how this would be a superior restoration over a full coverage crown for the majority of patients. As antiquated as Dr. G.V. Black`s principles on cavity preparations are, I still have to agree with him on the concept of "extension for prevention." Many times, with an inlay or an onlay, you are literally doubling the amount of margin length, which is the obvious area for problems to begin.

How do you justify placing a $500 (many dentists charge much more) MOL cosmetic, indirect onlay restoration, especially when the patient hears a couple of years later that you have to redo it once a lesion appears on the distal surface? If I were a patient, I would be extremely upset. At our seminars, I hear from many dental assistants about how angry patients get when this happens, or when the patient chips off another cusp on the same tooth. Many staff members are questioning their doctor`s motives, because they can relate to the patient`s financial well-being more than the doctor can.

Dickerson`s Counterpoint

Again, you distort the facts and confuse the issue with wrong information. You claim that an amalgam will last 20 years when a crown won`t. Statistically, that is not the case. The most obvious realization here is that you have no clue how to adequately do one of these esthetic restorations. Why don`t you come to LVI, and we will teach you so that you won`t have to continually redo them?

You also claim that your hygienist really wanted an Empress inlay and onlay. So you reluctantly did them. But you felt like a full crown would be better, since it would be "extension for prevention." You want to destroy the remaining tooth structure just so she won`t get a lesion on the interproximal of the portion not restored? Do you realize how crazy this sounds?

You claim that a patient will get upset if a lesion appears couple of years later and has to be redone. First of all, it wouldn`t have to be redone, since you could add to the restoration. But is it your fault this patient got new decay? And what if, in two years, dentistry discovers a way to restore it even more conservatively. Too bad if it`s already been destroyed by an overzealous preparation.

You ask the question, "How can you tell a single mother of four children that you do not provide this service and still sleep at night?" How do you sleep at night knowing that you destroyed healthy tooth structure unnecessarily? I feel so passionately about it being the wrong thing to do that I wouldn`t sleep at night if I did put an amalgam in someone`s mouth, knowing what I know about that restoration. That is the sole reason I stopped doing amalgams.

I do not buy into your claim that these esthetic restorations do not last as long. But let`s assume you are right. Personally, I would rather have the restoration replaced a few years before a crown would need to be replaced - as opposed to having the entire tooth destroyed - because who knows what will be available. Look at the advances that have been made in the past few years. The new Empress 2 is very similar to tooth structure. We might soon have the ability to actually clone tooth structure. But if the tooth has already been destroyed and the integrity of the tissue violated by margin placement, then it`s too late to conservatively restore the tooth.

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 #8

Steven`s Point

Another point brought up by amalgam-bashers is their unwavering belief about how much decay is under these amalgams. They say there is decay under every old amalgam they remove. How come I don`t see the same thing in my practice? Sure, I`ve seen it under plenty of amalgams (usually patients with poor hygiene) - but certainly not under all or even most.

What I do see is plenty of decay under most posterior composites. A new patient came in the other day with two posterior composites with recurrent decay. When I showed him the decay with the intraoral camera, he asked me if I could put in something more durable, such as amalgam. And they say no one comes in asking for a black filling! In the real world, longevity and cost are more important than cosmetics to most people.

Let`s assume that these dentists are correct about how decay is under almost every amalgam. Let`s use some common sense. If every amalgam leaks and gets recurrent decay, shouldn`t we be seeing tons of teeth needing root canals? I see on the average of 1,000 old amalgams each week. So, why am I only doing about 10 posterior root canals a week? Shouldn`t I be doing at least 50 or 100 or more if there truly is decay under all amalgams?

Let`s use the same reasoning about the belief that amalgams fracture off cusps. This is the standard complaint that all Dr. Bondos have with amalgam. Sure, I see it. I also see virgin teeth with fractured cusps.

But, if most amalgams are supposed to be fracturing off cusps all the time, why is it that I see only about one or two true cusp fractures (not caused from neglect and decay) per week out of the 1,000 old amalgams that I see? Isn`t that considered overkill (read overtreatment) to do more expensive procedures on all teeth just to assure that a few of them don`t break?

Key Point: If every amalgam leaks and gets recurrent decay, shouldn`t we be seeing tons of teeth needing root canals? So, why am I only doing about 10 posterior root canals a week?

Dickerson`s Counterpoint

You claim that you don`t see much decay under amalgams. This, again, flies in the face of the scientific research. Recently, two different university studies showed that amalgams with no ditching of the margins - that were deemed to be clinically excellent by a large group of dentists - had decay under around 50 percent of them. Again, if you will actually read the literature, I will tell you where to get it. In fact, if you have the past issues of my newsletters, it`s in one of them.

Joe, you claim that you see 1,000 amalgams a week. For God`s sake, man, slow down and smell the coffee! You are killing yourself if you actually see that many patients. And 10 posterior root canals a week on top of all that? You need our pulp-cap technique. We could change your life if you would only let us. You could spend some quality time with your patients and do a better job on the types of restorations that you claim don`t work, if you would only let us help you. Don`t be so stubborn on this. I want to help. As with anyone, we guarantee that you will find the program well worth the investment.

You also don`t think amalgams fracture cusps. Again, this is contrary to the research. It is the expansion properties of amalgam that cause this. Again, read the literature. You claim that restoring teeth with these restorations is overkill when not that many cusps fracture.

Why is placing a tooth-supportive material that prevents the tooth from fracturing overkill? Talk about overkill! In one instance, you claim that you would crown a tooth to prevent subsequent decay, and then tell us that - because we want to put a conservative bonded restoration on it that will support the cusps and prevent more aggressive treatment - that we are practicing overkill? I think you are reaching on this one.

Key Point: You claim that you see 1,000 amalgams a week. For God`s sake, man, slow down and smell the coffee! You are killing yourself if you actually see that many patients.

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.

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