by Michael DiTolla, DDS, FAGD
Recently, I had the opportunity to speak with one of my crown and bridge mentors, Dr. Bill Strupp of Clearwater, Fla. I think his commitment to quality restorative dentistry is truly amazing. This month I wanted to share some of Dr. Strupp’s thoughts.
Dr. DiTolla: I remember attending one of your lectures some 20 years ago. In fact, it was the year I graduated from dental school. In the lecture, you told a story about making a commitment to quality restorative dentistry when you did a buccal pit restoration on your son. At that time, you decided to use a cast gold restoration. Would you tell that story for our readers?
Dr. Strupp: The year was 1980. My son, Bill, was having a routine cleaning and exam. I placed an explorer in the buccal pit of (tooth) No. 30 and it stuck. This was his first cavity. It was not soft. With such a lesion today, I probably would clean it with air abrasion and seal it with resin composite. But, at that point in time, the restorative materials available to me were limited. In essence, I had four choices:
- amalgam, which was the material of choice for most initial restorations in my practice in which cosmetic concerns did not exist;
- resin composite, which could not be well bonded at the time;
- gold foil, which would have required an intensive search through my storage shed for products and information on material use (I had not done one since graduating in 1969);
- gold inlay, which is what I chose to do.
I prepared the cavity, did a direct wax-up, sprued it in the mouth to remove it from the cavity, invested it, burned it out, cast it, cemented it, cut off the sprue, and polished the gold. After all these years, he still has the restoration. There is no evidence he will need to have it replaced.
This story is important to me because when I went home and thought about what I had done, I went into a state of cognitive dissonance. I was placing amalgam for all of my other patients, but when it came to treating someone who really mattered, I did not use amalgam. I chose a better material knowing I would get a better result.
The realization that I was shortchanging my patients was life changing. I perceived they did not value good dentistry enough to pay for it. My perception was simply wrong. The only thing patients needed was my recommendation to do the proper dentistry. The next day I went to the office and discarded my amalgam and the equipment I used to place it. Since then, I have not done another amalgam in my practice. I admit there were many times when I almost returned to it. But I became adept at doing conservative gold castings and the resulting income was a significant benefit for many years. The rut I had climbed into during and after dental school changed to a superhighway to success because of the choices I made from this experience.
Dr. DiTolla: I remember reading one of your articles many years ago that listed approximately 20 reasons to do buildups. What are some of the top reasons for performing core buildups?
Dr. Strupp: Without question, the primary reason for core buildups is pulp protection. When microbes are denied access to the pulp, especially in deep cavities, less pulp death occurs. Equally as important, cores make restoring the case perio-restoratively predictable. Most cases I treat perio-restoratively involve removing failed crown and bridge and caries — both of which are generally in violation of the biologic width. When I do a core buildup and place a surgical provisional for my periodontist to remove at the time of surgery, he has a visual point that can be measured 360 degrees around the tooth. This tells him precisely how much osseous surgery is required. He knows the core must be 3 mm coronal to the bony crest.
If caries or an old restoration with caries under it is present at the time of surgery, he must guess where the final margin of the restoration will be relative to the bony crest. Invariably, excess bone removal will occur when one guesses about biologic parameters at the time of surgery. In essence, cores determine periodontal surgery in perio-restorative cases. Cores block out dark substrates and allow the use of translucent all-ceramic restorations that look like natural teeth instead of crowns.
Less precious metal is required when cores are done. Core buildups can increase the average dentist’s income by $300,000 a year.
Dr. Michael DiTolla is the Director of Clinical Research and Education at Glidewell Laboratories in Newport Beach, Calif. He lectures nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has several free clinical programs available online or on DVD at www.glidewell-lab.com. For more information on this article or his seminars, please contact him at www.drditolla.com.