How I Became a “Contrarian Leader”
It was never my goal in life to be a “contrarian” leader. I was trained by a master and pioneer in full coverage restorative dentistry who was highly regarded and respected in his lifetime. From him, I learned basic principles and techniques for creating full coverage restorations that have a well- documented 7-decade track record. The protocol I was taught came from the “roots” of modern dentistry and is based on a philosophy of sound engineering principles.
Because I had such a unique opportunity in my career, I decided early in my career that it was my duty to enlighten others. It never occurred to me I would be labelled as “controversial” or “contrarian.” I never thought that I would have had to swim upstream with all my strength to have a teaching career in full coverage restorative dentistry. I thought that dentists everywhere would unconditionally crave what I had to offer. How wrong I was. Attitudes about dentistry and dental practice changed literally overnight.
I think the attitude shift started with the dental schools. They failed students by starting to teach techniques for full coverage restorations that they thought would be easier for them to absorb. However, these techniques are not based on science, and do not have the track record of the full coverage dentistry that was originally done at the “roots” of modern dentistry . I believe strongly that if Dentistry is to advance as a science, anything new that comes down the pike MUST be compared to the standard that came before. This is NOT being done, and students are completely unaware of what came before. Worse, they have been indoctrinated into thinking that what they were taught in school is the only way to do things and the best way. Nothing could be further from the truth! Students also graduate with unprecedently large debts, and they have been forced to adopt a “production” mindset rather than a mindset of seeking excellence and education in order to pay off those debts. The combination of these two attitudes is a disaster for the dental profession and threatens to turn a profession that seeks to beat dental disease into a trade focused solely on economics and cosmetics.
New dentists graduate with such a lack of confidence in crown and bridgework, that they shy away from preparing teeth. Whenever possible they choose treatment options that they deem easier—even if those treatments violate sound principles of engineering, markedly extend the time of treatment and are considerably more invasive. I have observed the most prestigious post-graduate institutes recommend “minimally invasive” veneers over splinted full coverage restorations that would make more sense from an engineering standpoint of minimizing and distributing forces evenly. In my estimation, more than 90 percent of practitioners believe crowns and bridges are nothing more than “tooth coverings” instead of corrective restorations designed to eliminate the problems that cause dental disease.
Choosing the Right Treatment for Patients
This week I went to an excellent lecture given by two orthodontists on the use of aligners in orthodontic therapy. I went up to thank them for their excellent presentation. While on the “receiving” line, I noticed the case my younger colleague had in his hand to present to the instructor for an opinion. The X-Rays of the patient’s upper right quadrant showed generally good bone and roots. The first molar was missing, and the second molar was slightly tipped into the first molar position. The bicuspids were both restored with crowns. My colleague wanted to know if the back molar could be up-righted so an implant could be placed in the first molar region.
I saw immediately that the easiest solution for the patient would be to create a four-unit bridge and design the case so that the first molar appears to be the correct size and shape, even though the space was too narrow for a normal-sized first molar. I have done hundreds of such cases. The simple fixed-bridgework approach would result in the least amount of treatment for the patient to undergo and the fastest way to accomplish definitive treatment. When I suggested this treatment option to my colleague, he looked at me like I must have come from Mars. The idea of making a four-unit bridge filled him with horror.
I’m shocked that straightforward classical crown and bridgework is today almost universally discounted as a viable treatment option. What’s obvious to me with my background is that fixed bridgework usually the BEST treatment option. Bridgework–when done properly–can compensate for periodontal bone loss to prevent future bone loss and distribute forces evenly among a group of teeth instead of each tooth having to bear the load individually. From this engineering perspective, bridgework certainly makes the most sense! In addition, full coverage restorations designed according to the principle of the Mason Jar (the best method ever devised for food preservation) can virtually eliminate recurrent decay.
It is not necessary to upright molars in order to have a successful outcome.
While it is true that upright molars and bicuspids are designed to channel forces vertically along their long axes, tipped molars restored with ideal restorations have been restored with a high percentage of success. Patients are often unwilling to undergo additional time-consuming orthodontic procedures. Often, tipped molars result in narrower edentulous spaces that are not wide enough to reproduce the original tooth morphology. However, full coverage restorations can be designed so that all the teeth appear to be appropriate the size and shape. The esthetics can be incorporated into the design without making oversized teeth and without making hygiene difficult for the patient.
Single tooth implant placement is NOT better than quadrant bridgework.
One of the absolute worst places for implant placement is the spongy bone below the sinus of the upper posterior. Implants in this region have a high likelihood of failure. Sometimes, sinus lift surgery is necessary to place an implant long enough to carry the load of the restoration. Patients often do not want to undergo this kind of surgery. I have done hundreds of quadrant bridgework with a high percentage of success and longevity. The X-Rays in my colleague’s hand showed that the bicuspids already had crowns on them. Certainly, the teeth in the quadrant were not virginal teeth. Wouldn’t it be better to make a simple 4-unit bridge and avoid placing implants in areas of poor prognosis with extended treatment time? Quadrant bridgework can compensate for periodontal bone loss and solve the patient’s problems in the entire quadrant. A single tooth implant is piecemeal treatment, as it only fills a hole or a space and does nothing for the adjacent teeth. With piecemeal thinking, the patient’s problems in the quadrant are never solved.
Piecemeal thinking vs. Overall thinking.
It is no secret that today’s dental students are trained to think in a piecemeal way. Piecemeal thinking seeks to fill a hole or a space, while overall thinking seeks to solve problems that contribute to dental disease. The single-tooth implant is the poster child for piecemeal thinking. The single tooth implant only fills a space and does nothing for the teeth around that space. Go to any implant lecture or read any implant article in the dental “tabloids” and most of the adjacent teeth are not virginal, but have large fillings, crowns or will need crowns in the future. Most of the time these teeth have the beginnings of decay and periodontal bone loss. With the single tooth implant, the patient’s problems are never solved. Quadrant fixed bridgework, however, can correct all of these problems and often last decades when properly designed.
The dental insurance companies encourage piecemeal thinking because that is what they want to pay for. Do they even care about the patients they serve? I think not. Definitive solutions may cost more in the short run, but can actually save quite a lot of money in the long run. Isn’t it better to pay for dentistry that lasts 30 years rather than continually paying for replacement dentistry every 5 years? Outcomes should be important to insurance companies, but clearly they are not.
Don’t be a One-Trick Pony
The sad reality is that dental students are being indoctrinated to view implants as the optimal solution to every restorative problem. Don’t get me wrong. Where implants are indicated they can be a great treatment option. But where they are not indicated, they can precipitate a disaster that may not be easily corrected. Few practitioners have the wisdom to know the difference.
If practitioners had sound techniques for full coverage restorations in their armamentarium, they could pick and choose treatment options that are truly best for each individual patient. Sadly, many practitioners have great implant skills; but fewer practitioners today have great crown and bridgework skills than practitioners had in the past. As a result, patients almost always get the implant instead of the bridgework. This certainly fits the corporate agenda for the dental profession! Dental companies want to sell more implants, and business is booming!
The ONWARD program teaches sound techniques of full coverage restorations with a 70-year track record. I can show many full coverage cases that I did in the mouth 30 years with few changes in the X-Rays. While many practitioners chastise my approach to full coverage restorative dentistry as “old-fashioned,” the sobering truth is that they could never match what I have actually accomplished during the course of my career, what my father accomplished during his career, and even what my father’s teacher accomplished during his career!
One of the major problems the ONWARD program faces is overcoming the inherent bias in today’s young professionals. Science is not of paramount importance to the majority of them. I have seen them sneer at ONWARD’s philosophical approach and techniques that have developed over several lifetimes of study and documentation. I have heard every excuse in the book: it is not “high-tech,” it’s too “old fashioned,” or it’s “too hard.” Frankly, I am not impressed. Excuses are simply justifications for mediocrity. With a production mindset, the “easy way out” is always the best way. But paradoxically, the “easy way out” often becomes the “hard way out.” Without a mindset of seeking excellence and education, dental practitioners never learn from their mistakes in order to become better practitioners.
Going Against the Trend
You can see how wearing the “Contrarian Hat” is like wearing an albatross on your head. But I wear it as a badge of honor. My experience and background uniquely qualify me to make “outrageous”statements because I’m on “solid ground.” I know I am right, and I have the documentation to prove it. What kind of person would I be if I just let wrong statements and misconceptions win the day?
To borrow a phrase from a famous New York area radio talk show host [Bob Grant] who is now deceased:
“Somebody has to say these things. It has to be me!”
I know my controversial statements will not win me friends. But I am not here to win friends, I am here to be the “gadfly” of full coverage restorative dentistry, and hopefully steer others to pursue the right path. As Steven Sample says in his epic book The Contrarian’s Guide to Leadership:
“A contrarian leader knows that he himself must answer the questions of what’s right from both a worldly and a moral perspective. This at times will make his experience more exhilarating than that of other leaders, and at times more excruciating. But it will always be his experience—for which he willingly takes responsibility. And what could be a greater or more meaningful adventure in leadership than that1?”
1Sample, Steven; The Contrarian’s Guide to Leadership; published by Jossey-Bass—A Wiley Imprint; San Francisco, CA; 2002; p. 192.
Become the best practitioner in full coverage restorative dentistry that you can be! Don’t settle! Join the ONWARD program and learn how to do crown and bridgework with excellence and confidence, how to save “hopeless” teeth, and how to provide new options for patient treatment that you never thought of. Visit the website: https://theonwardprogram.com
Dr. Feinberg is available to give presentations. His CV and speaker packet is posted on the website. (https://theonwardprogram.com/about-dr-feinberg/) Dr. Feinberg can be reached at info@theONWARDprogram.com.