Clinging to Dogma in the Face of Challenging Evidence
I was at a study group meeting last week affiliated with a well-known institute. A case was shown, and everyone agreed with the instructor that teeth with no clinical crowns should be restored with buildups or posts. That is, everyone except me. I pointed out that posts and buildups are not retentive, and posts can actually do harm to teeth by setting them up for fracture. When crowns and bridgework fail, you can bet your bottom dollar that the posts are going to come out with the restoration. I informed them that I gave up doing buildups and posts years ago because they don’t work, can cause harm, and are actually a waste of time.
I can feel the stares like “daggers.” They must be thinking “Who do you think you are?” and “Where do you come off to make such an outrageous statement?” “We make money by charging for posts and buildups—we need that reimbursement from dental insurance companies!”
Everyone in the room is too shocked by my audacity to ask “Well, how in the hell do you restore them?” “Orthodontic extrusion?” No. “Crown lengthening?” Sometimes, but only a minimal amount—certainly not the amount necessary to create a clinical crown.
When practitioners are just about to accuse me of lying, I whip out my trusty box of dies flush with the gingiva that I made crowns for. I have done thousands of these teeth with a high percentage of success. They stare at the dies in disbelief, unable to process what they are seeing.
Then I really get their goat when I tell them that I don’t treat these teeth any differently than teeth with clinical crowns. I let the patients wear the crowns on a trial basis with Vaseline® ointment or Trial® Cement, which is a rubber-like material—and the crowns do NOT fall out. Once they are cemented, they NEVER come out and they never require re-cementing.
Now they think I’m totally nuts because they can’t comprehend how this is even possible. “Magical incantations?” No. “Obscure technology?” No. In fact all of these teeth were saved LOW Tech!
The reason they can’t comprehend how teeth with no clinical crowns can be saved without posts, buildups, orthodontic extrusion, or extensive crown lengthening procedures is because they have been indoctrinated to think according to a certain paradigm. I do not share their paradigm, as I was trained differently. That is why I can do things they can’t.
While the entire profession is focused on tooth structure above the gingiva to save teeth, I am focused on tooth structure below the gingiva. I do not care about any tooth structure above the gingiva. It is totally meaningless to me.
In the ONWARD paradigm “all that is needed to save teeth flush with the gingiva is a good grip on the root (adequate ferrule), a shoulder, and the precision fit of the casting on the prepared tooth.”
And here’s another anathema in the conventional paradigm: the margins of my crowns are placed subgingivally on UNCUT tooth structure, fairly close to the bone.
“GASP! You can’t do that! You are violating biologic width!!” Well, if it was true that I was violating biologic width I wouldn’t be able to show 70 years of documented cases where thousands of teeth were prepared in the exact same way, and I wouldn’t be able to show cases lasting in health with X-Rays for decades! I’m following the same protocol that came from Dentistry’s roots that my father’s teacher–Dr. I. Franklin Miller–pioneered! Isn’t it interesting that most presenters in the dental profession never show follow-up X-Rays of finished cases? The truth is that much less width is actually needed for the biologic attachment than what is touted by the conventional paradigm.
Truthfully, crowns and bridges fabricated according to the ONWARD protocol have an unmatchable track record of success and longevity. The restorations are not only are incredibly retentive; they protect the root surface from recurrent decay. Their design mirrors that of the Mason Jar cover, which is the best-known method of food preservation.
When I present X-Rays of cases in the ONWARD program, I always point out how the margins of the crowns are close to the periodontal bone and mirror the bone. That is the best architecture for health and for distributing forces along the foundation. I rarely hear speakers talk about engineering principles when it comes to crown and bridgework. Only cosmetics.
“So how on earth to you do this?” is the question that invariably comes next. I guarantee that most colleagues will not like the answer. “This result,” I tell them, “is only achievable with copper band impressions.” The answers are quite predictable: “That’s old fashioned! (You dinosaur!)” “That’s too hard.” “That’s too time-consuming.” “We can’t do that…we’ve gone digital and metal-free.”
Well, of course, none of these excuses hold water. The sobering reality is that the only way to register a complete impression of the root surface is with copper bands, unless the gingiva is completely cut away to expose the entire tooth structure (and no one would do this for an impression).
It is also a reality that getting impression material to the bottom of the sulcus with cord is almost impossible. All the impressions I see in presentations and in magazines are grossly inadequate in my opinion.
Lack of confidence in crown and bridge techniques is the reason dentists are shrinking away from full coverage restorations. As a result, there is an absolute epidemic of tooth extraction and implant placement. Many teeth that are extracted can actually be saved, but few practitioners know how to save them! It is the ONWARD mission to show them how, but the majority of practitioners are so stuck in the conventional paradigm that they refuse to open their minds.
The truth is that Copper Band impression taking is a skill like any other. Copper bands can be used with any impression material. It is the principle of the copper band that is important, not the impression material. But, as with any skill, there is a learning curve. The more a practitioner works at learning this skill, the better and faster he or she becomes. It takes me far less time to take a copper band impression than if I had to pack cord with elastic. If compound is the impression material, a faulty impression can be retaken in seconds—even without hemostasis!
It amazes me that the same practitioners who have learned how to manipulate complicated digital designs of restorations on the computer find taking a copper band impression too difficult! Maybe they don’t want to get their hands dirty. Less practitioners today know how to carve teeth, fabricate temporary restorations and do hands-on laboratory work. They think that these “hands-on” activities are beneath them because today everything can be done more accurately on the computer. In reality this is not true–the technology is not “there” yet.
It would be nice if CBCT scans could register accurate 360-degree impressions of prepared teeth, but to date this is not possible. Conventional intra-oral scanning is confined to tooth structure above the gingiva. Certainly, being able to register a complete impression of root surfaces with a scan would revolutionize dentistry and I would be all ears if such an advancement comes down the pike. I want to do better! It is the principle of registering an impression of the entire root surface above the bone that is important, not the method by which it is accomplished.
It is so sad that most dental practitioners do not have the ability to look at problems from different points of view. Why are they so stuck in the paradigms they were indoctrinated with? Why do so many practitioners refuse to even consider that their paradigms might be wrong? Why do they cling to these paradigms even when confronted with overwhelming evidence that in fact they are WRONG?
The real failing of dental education is not that they teach dentists techniques that I do not agree with. They have to teach students something in a very short period of time so that they can have minimal proficiency when they graduate. The real failing is that students believe that those techniques are the only way to do things and the best way to do things.
I gave a presentation to UT Houston Dental School a few years ago, and the meeting planners were really forward thinking. The presentation was dedicated to the memory of Dr. Jack Winston, a visionary in dentistry. What an honor it was to present at this memorial seminar! I will never forget the experience and the wonderful hospitality I experienced.
The audience was mixed and consisted of both practicing dentists and dental students at the university. The meeting planners were quite open about their desire to expose students to different points of view, so that they would be open to new learning in the future.
I presented some of the material that I just described—and naturally, that material conflicted with the teachings of the professors at the school. The practicing dentists loved the presentation and gave me rave reviews, but the dental students thought I was worse than stale bread. They were extremely upset that the material presented violated the teachings of their professors, whom they held in high esteem.
Is it any wonder that students today are so indoctrinated that they have tunnel vision? Doctors must be able to observe carefully, consider new ideas and advancements in the profession, and think “outside the box” in order to best solve clinical problems.
Open-mindedness is what truly separates those who ply a trade from those who practice a profession. Education really cannot occur without open-mindedness. Every practitioner is responsible for his or her own education; and no continuing education credit system can make them actually learn. On the first page of Dr. Winston’s autobiography, he quotes from Gibbon:
“Every person has two educations…one which he receives from others and one, more important, which he gives himself.”
[Jack R. Winston, DDS; Make ‘Em Smile: My Life and Career in Cosmetic and Restorative Dentistry; 1984]