is this malpractice ?

[hafnium45nm]

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Suppose you turn a moderate sized class II lesion into a full crown.

Is this malpractice? Can you be indicted by the state board for violation of professional standards?

I'm not saying I ever did this. But I'm asking because I'm seeing dentists who are doing crowns instead of class IIs. When I asked why, they said the composite fillings will eventually exhibit shrinkage and will fail anyway. They said it's easier to do crowns, which also help with production values.

 

[gryffindor]

It's not necessarily malpractice. The function of a crown is to replace missing tooth structure, in this case the structure is missing from one side of the tooth. It's not very conservative dentistry and isn't what I would want in my mouth to restore a class II lesion. Then again I went into ortho because I like saving enamel, not grinding huge chunks of it into oblivion.

 

[Daurang]

I am not sure if it's malpractice but it's unethical. Unfortunately, I see a lot of dentists do that.

 

[aphistis]

Suppose you turn a moderate sized class II lesion into a full crown.

Is this malpractice? Can you be indicted by the state board for violation of professional standards?

I'm not saying I ever did this. But I'm asking because I'm seeing dentists who are doing crowns instead of class IIs. When I asked why, they said the composite fillings will eventually exhibit shrinkage and will fail anyway. They said it's easier to do crowns, which also help with production values.

Is it safe to assume one of the dentists is your employer, the same one who wants you to do crown lengthenings without any training?

 

[tinman831]

You're running a very slippery slope when it comes to calling one dentists work malpractice. What you are describing is unethical, but if it can be justified, given the conditions faced, then it's not really malpractice. Crowns do exhibit marginal leakage and recurrent decay over time as well. The only real preventative solution would be to extract the tooth. 😉

 

[capisce?]

Troll alert.

Come on folks the writing is on the wall. Please don't feed the trolls 👍

 

[DrJeff]

Let's just play along for a moment here. Let's say that "moderate" class II is an MOD on #18, where the box width is just under 1/2 of the buccal - lingual width, and that tooth is in full function with #'s 14/15. You place the restoration check the occlusion, send them on their merry way.

Now, 3 years later, they come in with mesiolingual cusp of #18 fractured off around your restoration, and you tell the patient that they need the crown on #18. Now in 3 years time, you've billed them for an MOD restoration AND a crown, whereas if you'd just done the crown in the first place, you would have saved the patient the cost of the MOD restoration.😕 What's the better treatment scenario there(and this happens more often than you might think)

Personally, if I'm talking about a 3 surface class II lesion of moderate size, that option of the crown as 1st choice will very often pop into my treatment planning scheme, and ease of tooth preparation/ease of restoration/financial benefit has nothing to do with it. What it is about for me as I'm treatment planning those isn't necessarily what will "do the job" today, but what will most predictably "do the job" in 5,10,15+ years🙂

 

[Daurang]

Dr Jeff,

Your scenario is very plausible and your rationalization is sound BUT a large majority of teeth with large MOD will last a very long time and is not gonna break off a cusp like you want or hope. If you can treatment plan for a lot of crowns like that, then more power and money to you.

 

[tinker bell]

I see broken moderate size MOD every day. It depends on the population of patients that you serve. I have patients come in and ask why he always shows up for 6 months check up and get all his restorations done, why now his tooth all of the sudden fractured in half? Plus, why the well respected dentist did not tell him to get a crown in the first place 3 yrs ago? Why now he has to pay for crown lengthening, build up & crown?
Since I know most of my patients do not brush and floss. I'll be lucky if they brush twice a day. And there is no fluoride in the water. Therefore, If the lesion is moderate size, MOD, etc.....I recommend a crown or onlay. My policy is if the lesion become an MOD+, it's a build-up & crown prep.

 

[DrJeff]

Dr Jeff,

Your scenario is very plausible and your rationalization is sound BUT a large majority of teeth with large MOD will last a very long time and is not gonna break off a cusp like you want or hope. If you can treatment plan for a lot of crowns like that, then more power and money to you.

It's all case selection and treatment planning. If I'm looking at that MOD on #18, then I'm WAY more likely to tx plan the crown then say if I was looking at a similar sized restoration on #21.

It's just patient education and how I approach it. I simply explain to the patient with a couple of pictures of their tooth and then a little computer generated video that the Dentrix software that my office uses has(It's a program through Dentrix called "Guru" and it has some really well done quick explanatory videos about a whole slew of basic everday stuff we see/do). The end result is that as I'm discussing the final treatment for that tooth with my patient in a scenario like this, I'll often tell my patients that the crown will be the more predictable restoration for that tooth 5+ years from now, and let them decide from there. Roughly 3/4ths of the time then I'm cutting the crown on that #18. After being "geographically stable" in the same practice now for almost 10 years, I'm starting to see more and more of my 3 to 7 year old MOD restorations in posterior teeth show up with fractured off cusps around them, and as a result, I'm shifting my treatment planning philosophy for *some* of those teeth to account for what I'm seeing clinically in my patient's mouths around restorations that I placed.

 

[monreal]

It's all case selection and treatment planning. If I'm looking at that MOD on #18, then I'm WAY more likely to tx plan the crown then say if I was looking at a similar sized restoration on #21.

It's just patient education and how I approach it. I simply explain to the patient with a couple of pictures of their tooth and then a little computer generated video that the Dentrix software that my office uses has(It's a program through Dentrix called "Guru" and it has some really well done quick explanatory videos about a whole slew of basic everday stuff we see/do). The end result is that as I'm discussing the final treatment for that tooth with my patient in a scenario like this, I'll often tell my patients that the crown will be the more predictable restoration for that tooth 5+ years from now, and let them decide from there. Roughly 3/4ths of the time then I'm cutting the crown on that #18. After being "geographically stable" in the same practice now for almost 10 years, I'm starting to see more and more of my 3 to 7 year old MOD restorations in posterior teeth show up with fractured off cusps around them, and as a result, I'm shifting my treatment planning philosophy for *some* of those teeth to account for what I'm seeing clinically in my patient's mouths around restorations that I placed.

Thank you for the good stuff, "videos and guru"... I just don't like to loose all my options early in the process. When you give a crown now, then there is nothing you can do after that, except extraction. Why not keeping a card for the future? It's true that lower molars MODs are more prone to fracture, but also, crown limits failure is present in a few years. I would expect 5-7 years from the MOD (way more than 7 if onlay), then 12-17 years from the crown. My tooth is used for at least 20 years before being extracted.

After learning from your experience, I will keep my extra card for premolars and upper molars, although upper prems can be tricky too. However, no more moderate 18 MOD for me

 

[OceanDMD]

An onlay is just as good of restoration as a crown if prepared and inserted correctly. I routinely convert my MO/ DO/ MOD preparations on molars to onlay preps with coverage over any potentially compromised or functional cusps. The preparations are less invasive than a crown prep, although more difficult. I would be very carefull thowing "malpractice" or "unethical" labels out there. How long has the dentist been in practice? Has he/she watched longterm performance of personally placed restorations? I would much rather have an indirect bonded restoration placed than a layered direct composite, and no way would I let someone stuff that metal stuff in my teeth.😉

 

[DrJeff]

Thank you for the good stuff, "videos and guru"... I just don't like to loose all my options early in the process. When you give a crown now, then there is nothing you can do after that, except extraction. Why not keeping a card for the future? It's true that lower molars MODs are more prone to fracture, but also, crown limits failure is present in a few years. I would expect 5-7 years from the MOD (way more than 7 if onlay), then 12-17 years from the crown. My tooth is used for at least 20 years before being extracted.

After learning from your experience, I will keep my extra card for premolars and upper molars, although upper prems can be tricky too. However, no more moderate 18 MOD for me

Good points. I guess that personally I've also seen a few too many of the cusp fractures around my "beautiful" MOD restorations on a molar where when the cusp went, it decided to take a portion of the pulp chamber with it😱

Then not only did I get the "fun" of telling the patient that they needed a crown, but first I got to tell them that they needed crown lengthening and an endo.

Ocean brings up a great point about onlay's as options too.

As many of the d-schoolers will find out, there's SOOOOOO much you'll learn out in private practice from just getting the chance to observe how you're work wears/functions in your patients mouths overtime. And you'll find that rarely will you prep a tooth the exact same way/look at certain treatment planning situations the same way after you've been practicing for 5 years in the same place as you did on the 1st day you started at that practice.