Dental Info

  retentive crown preparation for all zirconium crown I was asked this question by a frustrated dental student. She explained that she tried in a zirconium crown and it had no real retention. She asked me why this had happened. I asked her to show me the crown and the model it was made on. Now truth be told, zirconium crowns can have more relief between the prep and the crown than some porcelain fused to metal or full metal crowns, but all types of crowns can have a problem with being non retentive due to a number of circumstances. I explained the following reasons for a poorly retentive crowns to result from our efforts: 1) the degree of taper. In theory crowns can be fabricated on preparations with miniumal taper (3 degrees), but many practitioners are unable to make this sort of preparation without producing undercuts. In their effort to make a preparation without undercuts, it is not uncommon to end up with preparations with greater than a 10 degree taper. These ...

 There are a number of different possible answers to this question. Teeth that are bothered by drinking cold liquids or breathing cold air could be suffering from "cracked tooth syndrome, a loose filling, gingival or occlusal erosion, deep decay, or a pulpitis. If you are experiencing discomfort when dealing with cold liquids or air it's best to see your dentist so he can try to diagnose why. When a patient comes in to a dental office with this complaint , the dentist should  interview them about when they have this symptom. (drinking cold or hot liquids or breathing cold air). Also do  they have intermittent pain on chewing food sometimes (cracked filling or cracked tooth)? In my office, after this brief interview I have my assistant take a periapical and bitewing radiograph and I examine the tooth or teeth in question specifically  looking for signs of a crack in a tooth or filling, decay approaching the pulp and/or dentin erosion. In addition I tap gently on the...

  I like shopping at Ikea. The prices are great and the furnishings are good looking, but I have some traditional furniture that I inherited from my mother or purchased from crate and barrel that has held up extremely well and I expect it to serve me well for many years to come. My Ikea purchases have  not always held up as well. I have thrown out all the rugs I bought there after several years and I do not purchase any upholstered furniture there.  There are some parallels that can be drawn with dentistry. Are crowns and other restorations the same regardless of which dentist we choose to help us? After all, all dentists we see are licensed and have received the same training in dental school? Also if I see a dentist with a well maintained dental office and busy practice, (with lots of nice google reviews) they must be pretty good? Sometimes yes, sometimes no, since the test of quality dentistry is how it holds up over time. Also the ability of a dentist to treatmen...

 The goal of dentistry should be to help a patient preserve their dentition  to minimize tooth loss and preserve their oral health. A dentist's ability to help his patients becomes apparent over the course of the time a patient is under their care. Recalling patients for check ups and cleanings is a key component as well as proper diagnosis and treatment planning will help further this goal.  Patients can help themselves by  maintaining  a good diet,  oral hygiene, and by following their dentists recommendations.  I believe a patients cooperation is one or the most important factors.   Using a well designed electric tooth brush and cleaning between your teeth either with floss or an interdental pic or brush will tend to keep the tooth surfaces free of plaque.  Plaque can cause both cavities and gum disease and the ability of a patient to keep their teeth clean between their recall appointments is a key to maintaining oral health. Th...

  Ok, I confess to loving spaghetti westerns, samurai movies as well as some of  Bruce Willis' movies. I also love movies with Don Quixote type themes. One man fighting against the odds in a corrupt and immoral  world. That being said the last few years, between my time spent teaching and maintaining my dental practice have definitely reinforced this sort of world view.  Five years ago , I shared my  floor with five  other dentists, an opthamologist, an internist and an acupuncturist. Now I am the last remaining of these tenants. My floor still has neighbors but they all have  moved to the 6th floor in the last year. The fact is that the last three years have been a rather wild ride here in NYC and many people that I know, patients included,  have moved away from NYC. Others working mostly remotely from our suburbs. Thankfully they still come into to see us for their check ups and cleanings, just not as frequently as before when it was more c...

  A   rōnin  ( / ˈ r oʊ n ɪ n /   ROH -nin ;  Japanese :  浪人 ,  IPA:  [ɾoːɲiɴ] , meaning 'drifter' or 'wanderer') [1]  was a  samurai  without a lord or master during the  feudal period  of  Japan  (1185–1868)  word  rōnin  literally means 'wanderer'. It is an idiomatic expression for 'vagrant' or 'wandering man', someone who finds the way without belonging to one place. Probably I have been binge watching too many Japanese Samurai dramas, but the thought occurred to me that young specialists  sometimes display some similarities to Ronin Warriors. They may have developed mad skills but they have no allegiance  to one dental practice. Instead they can function like hired "gunslingers" who work for wealthy practices that desire specialists to work part time one to 4 days a month. More and more  dental  practices are choosing to provide  dental specialties services in h...

 When patients ask how long do crowns last, I usually answer about 10-20 years. That being the case, I do not automatically replace crowns that have been in service longer. Last week a patient came in and asked if it was time to replace his single gold crown since it was pretty old. I replied that crowns do not have any expiration date and that I would tell him when it was time for his crown to be replaced.  It is true that some long standing crowns that look  good on a radiograph may have some cement wash out along some of their margins, mostly we do not replace crowns until there is evidence of some deterioration around the margins or there is a perforation on the occlusal surface.  There is a risk of causing a problem when replacing a crown that is still serviceable iincluding  the crowned tooth becoming more sensitive or even requiring a root canal procedure. While this risk is small,  to my mind it's best to continue monitoring older crowns to see...

 Last week one of my long time patients came in and had a cleaning and exam. He has a history of a extremely high caries rate and apparently his dry mouth has contributed to his problems. He complained that when he sleeps his mouth gets really dry and we reported that he sleeps with his mouth open.  I find that I too have been sleeping with my mouth open and I wake up multiple times per night with an extremely dry mouth. I asked him if he had some time and we could watch some lessons on Spear Online about "the Seattle Protocol" which is an introduction to "sleep dentistry". He said he did and we watched about 30 minutes of the lessons called Nasal Breathing Therapy . I had remembered watching these awhile ago and there was a mention of taping the mouth shut at night (   Buteyko Mouth Taping  )  so that mouth breathing might be discouraged.  I should add that I have been quite skeptical about sleep dentistry but I have little or no firsthand experience ...

Although NYC has over 8 million residents, I do run into patients from time to time. It can be disconcerting if I don't immediately recall their name but some are clearly more memorable than others and their personal details are forever stamped into my longterm memory banks. Yesterday I was teaching at NYU College of Dentistry and a student asked me to please go over her examination of an 88 year old patient. When I came over to her cubicle, I recognized her patient as one of my long time patients whom I haven't seen for more than 10 years. I recognized her immediately and greeted her happily "Hi Gail!". She looked confused and I removed my mask and said "It's Dr. Spindel". We chatted for a few minutes about her and her family and seeing her really made my day. She had kept all her teeth and they were still in great shape. I'm not sure why she stopped coming to the office (I think she told Ida she was on a fixed income and felt she could ...

 Screw retained implant restoration with properly shaped emergence profile  The angle and the shape of the abutment or screw retained crown should be flare slowly and be concave if possible. This shape will not press on adjacent bone and tissue that will support the implant restoration. This should minimize inflammation and facilitate the dentists ability to full seat and torque down the implant restoration. A properly designed restoration is kinder to the surrounding tissues and may make their continued health and preservation more likely as well as facilitate proper cleansabilty by the patient. Often times these restorations are designed by technicians who don't always understand the principles involved with proper perio prosthodontic design. The photo below shows an area about one mm away from the platform switch implant where the interface has a small ledge that brings it closer to the osseous interproximal bone. This is usually correctable by carefully using ...

 I have been a dentist for over 40 years and at this point most dental procedures are straight forward and relatively easy for me. Taking care of  people with differing expectations can sometimes be the more challenging part of dentistry. I personally enjoy chatting with patients while I'm treating them. Of course sometimes our conversations can be more of a monologue since at times their mouths are propped open and they can't contribute easily. Most of the times our banter serves to distract my patients from the procedure they are having done and lessens their anxiety, but not always. I was cleaning a long time patients teeth and it became clear that she wasn't enjoying the conversation and really just wanted her cleaning finished without a lot of chit chat. . She seemed to be channeling Sargent Joe Friday from an old episode of Dragnet ( just the facts please!) It can be hard to figure out why a patient clams up, but there are a number of possible explanations including...

 I went to Costco and took it yesterday. My last booster was in April and according to the FDA website"  "i ndividuals 12 years of age and older  are eligible for a single booster dose of the Pfizer-BioNTech COVID-19 Vaccine, Bivalent if it has been at least two months since they have completed primary vaccination or have received the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine" This is the fifth covid vaccine shot I have taken and so far I have been lucky. To the best of my knowledge I have avoided a Covid infection. I wear a N-95 mask while taking public transportation and treating patients. That being the case,  lately I have not been a complete hermit. I attend small group study club meetings where food is served and none of the attendees are wearing masks and I occasionally eat out at restaurants with several people sitting at my table. Many of us are "through" with Covid, but apparently Covid is not through w...

According to Britannica.com :" This oath dictates the obligations of the physician to students of medicine and the duties of pupil to teacher. In the oath, the physician pledges to prescribe only  beneficial  treatments, according to his abilities and judgment; to refrain from causing harm or hurt; and to live an  exemplary  personal and professional life." Since dentists are essentially physicians of the mouth, the Hippocratic oath applies to our profession . That being said, as more and more cooperate entities are getting involved with healthcare, sometimes it seems that this oath is being forgotten. As far as I know MBA's are not sworn to uphold this oath and and in my opinion it seems that their goal is to increase efficiency and  generate  maximum profits. This can present a conflict to both dentists in training and to licensed dentists as well. Often to improve access to potential patients they feel compelled to treat patients with insurance ...

  A number of dentists, feel that cleaning teeth is "too simple" for them to spend time cleaning teeth (also hygiene "production" is less than other types of procedures that a dentist may perform.).Dentist's whose heart is not into performing cleanings may not do their best job. In that case most hygienist will do a better job at cleaning their patients teeth. I do about 20% of the cleanings that are performed in my office. I enjoy doing some cleanings and I have patients that ask for me. Other patients request that they be scheduled with Elena (our hygiene "Angel"). She is quite gentle and extremely nice and has been performing cleanings in our office for over ten years.  This past vacation I rented a house in Cape Cod  and my son invited some of his friends who are recent graduates of NYU's dental school. Some will be working in dental offices as a first year associate instead of doing a general practice residency.  I advised them to not be ups...

 The problem with cleaning out cavities that are at least partially below the gingiva is that it is easy to cause bleeding when prepping the cavity for a filling . In my practice I employ ultradent cord to retract the gums away from the margin of my preparation. Often I need to use two cords... a smaller cord first and and slightly larger cord second. These cords are saturated with either hemodent or viscostat. Hemodent is often better because it doesn't get "brown" ferric sulfate infused into the gingiva and preparation. Hemodent (aluminum chloride) is a clear solution.  Ocasionally I will remove some of the gingiva with a rotary diamond or a periodontal currette (a gingivictomy) because there is too much gingiva to be retracted by retraction cord alone. I find that ferric sulfate (Ultradent's Viscostat) will arrest the resulting bleeding that occurs due to my gingivectomy.  Once the gingiva is pushed away from the margin , then I am usually able to clean out the d...

 Since we close for the last two weeks in August many of our patients who we saw in August who need dental work are likely to schedule their next visit after labor day when we reopen. Since most dental insurance plans renew annually starting Jan 1rst, many of our insured patients have only the next 4 months to use their remaining dental benefits.  Most that are in need multiple procedures prefer that we sent in a pre-certification to their insurance company prior to commencing treatment since this will help them determine out of pocket costs. The problem is that some of the insurance companies are getting more slow at processing pre-certfications and claims. It is not that unusual for them to claim that they haven't received our mailed documents. So the point of this post is to encourage our patient to not delay scheduling their continuing care appointments ( check up and cleanings as well as completing any planned treatment), This will allow these these to be billed to their...

 Our office is closed from August 19th - Sept 5th. As I have most summers for the last 64 years, I will be spending  time in Woods Hole, Ma. My son and I have rented a house for these two weeks and will enjoy our time swimming, biking and visiting with friends. After a couple of weeks in Woods Hole, We  feel rejuvenated and definitely more fit and happy. I use this time to get myself back in shape by biking every day to Falmouth and back. The Shinning Sea bike path is partly along the water and is beautiful and while NYC has plenty of places to bike, the bike path here is easily accessible from our cottage.  I usually start out my vacation with only enough energy to bike 2/12 miles to Falmouth , where I stop at Coffee Obsession to have an iced coffee before heading home again. As I get in slightly better shape, I extend my trip by several more miles to Sippewissett salt marshes .  While some of my friends don't understand why I don't use my summer vac...

 There are a number of factors that contribute to developing a successful  dental practice. Dentists  need to  develop their clinical skills, leadership ability,  treatment planning ability and also  their salesmanship. In addition successful dental practices need  a sufficient number of active patients who continue to return for treatments year after year . 1. Obviously possessing clinical skills is very important to all dentists. No one wants to go to an incompetent dentist or even one who is just "good enough". Most patients want a highly skilled dentist who will be able to provide them with durable dental restorations that help preserve their dentition. In addition patients desire dentists who provide cosmetic restorations that will keep their smiles looking attractive. 2. Successful dental practices need a hardworking and loyal staff that enhance the delivery of dental care. After all most of a patients interactions are with our staff ....

  Last weekend I booked my reservation for the annual Spear Summit. This event is held yearly in Scottsdale Arizona and Spear brings knowledgeable domestic and international speakers. Whenever I have attended I have enjoyed the trip and the information on dentistry that I obtain. Also the other attendees are either members of the Spear faculty club or other fellow leaders of Spear Study Clubs. I haven't attended one of these since 2019 and am thinking that it may a be a good time to return to an in person Spear Scottsdale meeting. Usually this meeting is held over several days and requires me to close my practice for a day or two.  While I haven't made my mind up for sure, I know I would enjoy this meeting and the opportunities to meet with other like minded dental colleagues. My only two reservations are dealing with airline cancellations and the increasing rate of Covid infections that we have been experiencing. I plan on wearing my mask at the lectures and meals can be...

 My son graduated from NYU College of Dentistry this June. I started teaching at the School shortly before he started 4 years ago. I had always wanted to resume my teaching activitie there ( I had taught briefly in the 1980's) and clearly this was a good time to start teaching again.  I asked if I could be assigned as a clinical instructor of dentistry in NYU's Department of Comprehensive Care and Cariology. As such I would be directly supervising third and fourth year students while they were in the clinics treating patients. I suspected I would be a good instructor and I could give something back both  to my community and to my profession.  I was able to help the students and their patients achieve better dental outcomes and I found that I benefited in other ways as well. I found that the challenges that I faced each week ended up further sharpening my clinical skills and accelerated opportunities for my own learning and definitely improved my clinical dexterity ...

Implant with broken crown part still attached  If your implant crown has a bite that has changed , its time to see your dentist right away. This often can mean that the screw holding in either the abutment or crown is coming loose. This should be addressed since leaving it for a later time can cause the implant screw to break, or even cause the implant to fail if due to due to a failure of the osseointegration that secures the implant to a patients jaw. No matter what the cause is, its best to notify your dentist and ask to come in for a visit as soon as they can schedule an appointment (hopefully with in the week).  broken screw retained implant crown Two weeks ago a patient called me up to let me know that her bite had changed with her implant crown and I saw her promptly. By the time she came in her screw retained crown had fractured and left part of the crown still attached below the gingiva. Fortunately the screw had not broken and I was able to r...

 I find that it is helpful to leave several hours during my working week that are not to be scheduled with patients for me to treat. This allows me to tackle tasks that require thinking or may be time consuming, unpleasant or both.  I can't speak for other dentists, but some of these activities make me anxious or put me in a less than positive mood... Probably it is best not to treat patients when dealing with some issues.  Four years ago, I started teaching part time at NYU College of dentistry on my day off (Friday) and Thursday morning for three hours. Prior to working at NYU, I left open time on Fridays or Thursday mornings for non clerical activities. As much as I enjoy teaching , I don't like having limited time  to for my non clinical hours and was forced to deal with these activities between scheduled patient appointments. Two weeks ago I requested to limit my teaching hours to Fridays and I have resumed my old habit of scheduling time consuming cleric...

 The short answer is there is no one best crown for every situation, but more and more dentists are opting for all ceramic crowns.... either Zirconium or lithium dislicate. They are used in different clincal situations. Please be aware that This post is not intended to be a deep dive into the subject, but may answer may questions about all ceramic crowns So what be the appropriate indications for using the different types of ceramic crowns ( full thickness milled zirconium , Porcelain fused to Zirconium, full thickness lithium disilicate( pressable or milled),  and litium disilicate layered with porcelain. How to make sense of all these choices? Ok , lets try and clarify the different options and which is best in different situations.  Presently, monolithic zirconium crowns are the most commonly made crowns by dentists nationwide. These come in three Primary types; High opacity, medium opacity and high translucency. The opaque version is somewhat stronger and fracture r...

 It seems that our entire society is experiencing a consolidation of services. Amazon, for example,  essentially drove most of the smaller book sellers out of business.  Then Amazon added other types of goods and now it is the behemoth of vendors seemingly selling anything the heart desires. We have seen the advent of large pharmacy chains that are providing medicines (Walgreens, CVS, Rite Aid) and they have more or less eliminated other smaller privately owned  pharmacies. Presently large hospital systems are swallowing other smaller hospitals as well as purchasing privately owned medical practices.  The same trend can be observed in dentistry, where investors have funded chains of dental offices that are buying existing privately owned dental practices.  Many of my graduating seniors at NYU College of Dentistry have received generous offers with starting salaries that are over $150,000 per annum . These dental chains often have modern well appointed o...

 I get asked this question a lot by my patients. While in the last year we were seeing fewer patients, starting in this March I noticed an increase in patients scheduled in my office. Many of these patients were  "lost in action" during the protracted Covid Pandemic. Many  returnees mentioned that after their recent booster and the simultaneous lull in New Covid cases in NYC, they felt safe enough to visit us.  While my staff and I were happy to see them again, many have experience dental problems and put off seeking treatment until after they were full vaccinated. The truth is that with or without current vaccination seeking dental treatment is a safe option and probably is preferable to delaying dental care indefinitely until the pandemic is over. This is especially true because our pandemic seems to becoming endemic ( it is here to stay... Like the season flu or the risk of contracting a common cold).  I am not implying that proper precautions should not be...

 I have been practicing in my own private office since 1984 and the business has not changed that much with the exception that it seems that insurance companies are facilitating a race to the bottom. New dentists signing up for a plan are told they must accept lower reimbursement schedules. Although dentists are not allowed by the law to set their billing rates with each other, insurance companies can in effect force lower rates for dentists signing up for the first time. Its seems to be a reverse type of "price fixing" scheme.  This has the effect of lowering the net profits for dental practices, since after all the overhead bills are paid, what is left over is "profit" that goes to the owner. Traditionally in an owner operated dental office the dentist ended up being paid a percentage of billings. While it used to be common for fee for service dentists to be paid about 40 percent of their profits, most practices have seen the owner / operator's percentage shr...

 Dentists, like most people, are creatures of habit. For many years we have been told by laboratories to provide 1mm shoulder or chamfers for our ceramic crowns. While this may make it easier for our labs to fabricate restorations, but now that they are predominantly fabricating milled zirconium and lithium disilicate restorations this amount of chamfer depth is more than the minimum needed. For those of my readers who are wondering what a chamfer or shoulder refers to, it is a shelf that provides the finishing line for this type of restoration.  Since this area is not the part of the restoration that has to deal with occlusal forces, probably all that is needed is about  a .5mm deep chamfer (or shoulder).  Since conserving tooth structure can ultimately influence the success or failure of a crown and the tooth supporting, preserving tooth structure is very desirable. The deeper our chamfers are, the closer we get to a tooth pulp when we are preparing a vital t...

We are a family dental practice specializing in Implant and Cosmetic Dentistry. Probably  my dental practice is somewhat out of step with the directions most businesses are going. There seems to be a general movement away from owner /operator businesses. No matter which way we turn there seems to be the trend toward consolidation of businesses This supposedly helps to “increase efficiency and cost effectiveness”. As far as I can see , this trend has not improved the general level of service and satisfaction that customers receive. Instead, this trend has resulted in fewer choices for consumers and often less competition between providers. When calling these businesses  we are often forced to spend a fair  amount of time listening to automated messages while we wait  to possibly speak to an actual representative. This trend has already impacted the delivery of medical care and will likely increasingly effect dentistry as well. In our “old fashioned” dental office we...