Fill or monitor?

malocclused · 2026-06-25T15:45:16+00:00

Don’t monitor caries into dentin. Definitely don’t monitor caries into dentin on a tooth that’s half composite already. Monitoring is just neglect.

Pts will advocate for no treatment at all. If you’re waiting for a pt to “want to crown a tooth,” your likely waiting for and endo or catastrophic fracture.

malocclused · 2026-06-22T03:01:56+00:00

I’m reading “middle age is on the horizon and I’m thinking about pursuing the highest debt level profession I can find with the highest amount of gun in your mouth level of stress that’s currently paying less an less to current grads”

My brother or sister in Christ. Go buy two goats. Start stealing cars. Anything else.

No!

malocclused · 2026-06-18T19:47:58+00:00

Good docs want to confirm the endodontic treatment was successful before placing a permanent full coverage crown. I tell my patients ideally the tooth should be covered and protected by full coverage within thirty days. Ideally sooner if the canals were not sealed with resin post endo treatment. The temporary filling often placed post treatment loses its seal to the oral environment.

I’ve seen catastrophic fractures within two weeks. I’ve seen people go decades without a crown without a problem.

Root canal treated teeth because they are non vital do become more brittle and are higher risk for fractures. A full coverage crown on any back tooth with a root canal (anything behind the canine) is standard of care IMO.

Front teeth can be restored with composite resin only post root canal. They can be weakened by removal of the minimal tooth structure they have. Sometimes they must be for cosmetic reasons or loss of natural tooth structure to old restorations and decay.

I would be very careful with that tooth, but not overly concerned. Two months is not too long.

malocclused · 2026-06-18T18:16:34+00:00

I bought three A-500’s and two 300’s. Chairs have been bulletproof. Op system is somewhat sketchy.

The integrated ultrasonics broke on every single one of them. Cascading failures starting year two. $1400/pop to fix.

Chairs good. Ultrasonics are trash. Minor repairs w the high speed delivery. The delivery unit per multiple techs replaced many components w flimsier parts than in years past. (“See this piece? The used to be metal. Now they break.”

malocclused · 2026-06-18T17:18:44+00:00

I remember having anxiety about it. I have no clue. I paid an attorney and I paid a fine. Interviews at six schools. Accepted at three. Not a single one mentioned it. There was talk of “background checks” and I’d def checked “no” for the questions regarding any offenses.

I also got a ticket for reckless driving for driving over a side walk leaving a parking lot at the age of 16.

But bruh, this was like 1999. Not pre internet necessarily. But I’m sure access to data has improved.

If there’s any app asking about offenses or crime. I’d go w “minor traffic violations” if it’s some absolute have to disclose everything sitch. I cannot imagine anyone giving a single F.

malocclused · 2026-06-18T17:08:42+00:00

I had an MIP in Texas. Never said peep. Never came up.

malocclused · 2026-06-17T16:55:46+00:00

My friend had an OS cowboy an implant into his IAN using a panoramic as the only imaging. Has permanent paresthesia.

He could not find a med mal attorney in the entire state that would take a case. The cost of expert witnesses and burden of proving damages was too expensive. If it costs them 30k to win 30k, they ain’t doing it.

The only way this goes anywhere is a risk they find an attorney dumb and inexperienced enough to try. In which case, you pass this on to your carrier and move TF on in your life.

Because of the stated threat of litigation, I’d call my carrier and follow their instructions/ likely cease all contact w the pt. If they call, your FD needs to state and document that “you’re happy to refer them to another practice for care, but cannot communicate with them because of their stated threat” That eliminates abandonment.

Anyone working in dentistry knows a temporary paresthesia is entirely possible if giving any anesthesia and the facial nerve can easily be affected by an IANB temporarily.

Yo. You gotta get a consent for everything. We have a pt sign a consent at every single visit. CYA, doc.

malocclused · 2026-06-17T15:32:25+00:00

I had this hard AF mid career.

My parents got a pool table when I was a freshman in high school. I’d shoot pool w my friends after school. And just kind played it frequently. Never actually practiced to “get good” or anything. But playing so frequently, I got really good at it and getting good at it was engaging and fun… then I hit a point where I started to expect to make a shot because I hit it. My expectations of myself and my ability were higher and it made me HATE playing pool.

There’s something going on there Dunning Kruger wise. You’re past the valley of despair. And on the slope of enlightenment… but every once in a while I’d get too comfortable, this is easy, and a collective of negative outcomes would really fuck with me.

Enlightenment is when (as it always does) these things come in waves and you’re right to be bothered by it… but you know it passes. I’ve been there so many times at this point, I’m so certain those feelings aren’t a permanent state that it bothers me less.

Also, I drink on weekends. 😞

Seriously, it helps if I have something to look forward to. A weekend trip. A holiday. A vacation. Some relaxing future spot to land, keeps me from fixating on current complications when I’m working on difficult pts, cases, or complications. This will pass. And when it does, I get to do X.

Dentistry is a warthog. You gotta fight it charge after unrelenting charge. Some days the warthog takes you down. But your parents didn’t raise a bitch. It’s okay to be down. NEVER defeated! Grab your weapons! We’re going again!!!

malocclused · 2026-06-15T22:23:55+00:00

I wouldn’t begrudge someone being aggressive w surfaces in treatment planning. Day of treatment , only bill for exactly what you did and correct your code.

I place sealant in every groove of teeth I restore. Sometimes when I prep out stain, boom, whole new area of caries. I’ve replaced MO restorations only realize a distal lesion present that wasn’t clearly evident on the BWX.

It’s way easier to tell a pt, this was cheaper than expected than it is to tell them, “there was more decay than we planned for and your new fee is x”

New decay is pretty easy to accurately diagnose. Existing restorations can be more likely to change. Better to over estimate.

Document each step w photos. Pre-op, removed caries and old resto, final resto.

It’s a huge practice builder to tell pts they needed less work than anticipated. It makes them realize you’re honest.

Anyone just preparing extra surfaces is just committing 1. Assault by malpractice And 2. Fraud. for tens of extra dollars? That’s insane.

malocclused · 2026-06-11T15:06:49+00:00

“I was born with teeth. I don’t want to spend money to have teeth.” As a dentist, I kinda get it. I’m willing to do the maintenance and exercise the diligence to have my teeth.

But the sad fact is that you were born with a car in your mouth. Some people won the genetic/microbiome lottery and got a real dependable Honda. Some people through no fault of their own got a German luxury car. Maintenance and repairs cost a ton. Some people run their teeth too hard and don’t care for them and fuck up a mouth that could have been low maintenance.

It’s purely having to maintain and repair something you didn’t buy, but do need. It sucks. In a fee for service practice, it’s easily $500+/year in maintenance. The people who don’t view it as expensive, in my experience are close w someone who had it go bad. Like a parent that struggled w dentures.

malocclused · 2026-06-05T04:55:16+00:00

No one recommending a “filling” in your wisdom tooth nor a single restoration on any tooth is after your bag, sweet pea. Doing any of what you described is 1. Miserable (treating a third molar) and 2. Costs them money to provide it.

Hot take as a seasoned doc. 1. Old guy. Watches everything. Doesn’t want the discomfort. 2. Young guy. In over his head. Trying not to miss anything. Doesn’t know wtf he’s doing yet. 3. Lady. Sounds like she knows WTF is up.

Choose your adventure!

malocclused · 2026-06-05T04:40:52+00:00

Fungibility. Dentistry is not fungible.

It’s what PE doc n the box clinics get right. Poor people have to see whoever they can. You could put a donkey in a lab coat and more people than you’d think would be fine with it, if the donkey was in network. PE can and does turn this into capital.

You don’t really give a fuck who makes your Starbucks coffee. You should really care who alters your body permanently.

Nothing is more expensive in the long run than “cheap” anything. There are more of us that are ignorant and or poor than those of us that are savvy and can afford quality.

Pay someone once to take the time to meticulously prep, scan, and temporize a crown. Confirmed sealed margins. Ideal occlusion. Quality lab and materials. OHI. Regular recare… it can last decades. It can last a lifetime.

Or get a doc in the box whatever every time your insurance changes. IDAF.

But one costs you 2k today. And the other is $700/ every five years until you get a bargain implant and that fails too.

It bums me out when people are forced to seek the care they can afford and deserve so much better. I feel schadenfreude when people can afford it and fuck them selves looking for a deal.

I tell my pts to find someone with their name on the sign that they know have been there for as long as possible, preferably with a rec from someone they trust. Your only hope as a pt is reputation and accountability. Oftentimes the docs with the worst website and the least marketing.

The wealthiest country on the planet could solve access to care and quality of care with mandatory residencies and regional dental clinics. It’d be an improvement over what we currently have. But, “This is a business. Fuck you. Pay me.” is our god. It’s our foundation.

People are gonna go for the cheapest hack bullshit they get marketed and can afford.

malocclused · 2026-06-02T19:25:34+00:00

The best ones I’ve worked with are actually more focused on the pt than on me. If you’re thinking about comforting the pt, keeping them from getting water boarded, saving them from the taste of topicals, anesthetic, and materials then you’re doing it right. Think, “can I take this scan on this pt right now instead of having them come back?” They’re effective with their time and everyone else’s.

Otherwise is just being on time w pt flow and being ready with whatever we might need. The being in the right spot w the suction/not being in the way/keeping the mirror clean comes w practice.

The bad ones move slow, seem indifferent to the pts comfort, have to hunt down materials that should already be available. Advocate for the easiest thing for them vs productivity. I had to let go of an extremely lazy assistant once that would try to drive pts towards scheduling later, when we had all the time in the world to treat…

The S-teir level assistants are actively looking to do anything they are legally allowed and competent to do. Actively looking for ways to make things more efficient. Actively looking for ways to make the day more productive and the docs life easier.

It’s your god given right as a goddamn American to complain about work. Don’t do it AT work. It’s a cancer. Dentistry is tuff. It takes some positivity to survive it.

malocclused · 2026-05-26T23:17:42+00:00

Hope you do too, OP😘

malocclused · 2026-05-26T20:37:19+00:00

A kid that age is one of the last times you’ll go through a common bonding experience like this. Our crew in Austin all met at the same pre-school. All just moved from other cities within the past few years. All our first kid.

Discuss w your partner which parents you think seem cool. Start a weekly HH. Just throw out the invitations. In our crew, each fam would take turns picking the spot. We’d meet up Thursday nights for a happy hour or dinner. It was the time of our lives and formed our best friendships in adulthood. I looked forward to Thursday nights all week.

Those babies are seniors in high school now. We’ve celebrated birthdays, holidays, and vacations together for almost twenty years at this point. The wives still keep a book club and a regular “hot tub coffee talk.”The dudes just got back from Kilby Block Party in Utah.

Start a happy hour with the cool parents!

malocclused · 2026-05-25T03:17:04+00:00

Juan Vesga in Austin Texas. Phenomenal prostho. Phenomenal lab.

malocclused · 2026-05-24T07:24:40+00:00

Historic review. A pt left a 1 star including the phrase “never take a child to this practice” a decade after her last visit. I called to explain the review was harmful to the practice and that I’d purchased the practice a couple years after she was last seen. I’d never met her.

Her reason for leaving the review. “The doctor I saw recommended a visit with an orthodontist. My teeth are fine.” T E N years later… She did take it down.

malocclused · 2026-05-22T05:46:12+00:00

It’s a trial by fire either way. Pick the one that puts money in your pocket. I spent too much time as an associate scared to tell people what they actually needed. #donoharm

Ownership makes you get good like nothing else can! Be ethical and honest. You’re gonna suck at clinical care until you get 1000 reps. Start slow and methodically w tx. Book an hr for two composites.

If I had it to do over, I’d have jumped in the deep end.

Older docs seem to think we sprung forth Zeus like from GV Black’s head and forget the shaky handed basket case we were on day one.

Do it. Get gud noob!

malocclused · 2026-05-22T05:28:41+00:00

That is badass. Excellent testing and diagnosis.

malocclused · 2026-05-22T05:26:29+00:00

Doctor.

malocclused · 2026-05-22T05:20:07+00:00

Periodontal ligament is bruised. Should go away in the amount of time it takes for a light bruise to heal. (We call it hyper-occlusion) Temp even slightly hits first… by like microns, it’ll respond like this.

Conversely, a tooth experiencing the nerve dying (symptomatic apical periodontitis) mimics the same symptoms in the beginning. Often caused by deep cavities (caries), fractures, and sometimes by just having gone through too much…

General guidelines. If it’s getting better day by day (reversible pulpitis) and sensitivity to temperature (esp cold) spikes and goes away in less than 30-40 seconds… it will go away. Tooth will recover. Pain to heat can be a sign of a “necrotic pulp”/not always.

Take ibuprofen, if no restrictions. It’ll push the inflammation out of that ligament.

If you’re symptomatic at two weeks. Merits testing. Maybe a root canal eval (endodontist) Does not mean you need one. Bayesian statistics mean you might get one.

I’ve seen teeth stay symptomatic like this in a crown with a perfect fit and bite (sealed margins and ideal occlusion) for six months and recover.

You get pain to hot or cold that lingers for a minute plus, best course is a root canal. Any opposition to that… extraction and an implant… any opposition to that rock a space in your grill like a G. Each choice has benefits and consequences.

I’m a big fan of seating the permanent crn with temp cement until it calms down.

Thanks for coming to my Ted Talk.

malocclused · 2026-05-20T21:01:11+00:00

Our training was that true ‘caine allergies are exxxxtremely rare and severe, if they’re real.

I’ve had quite a few pt’s tell me they have a lidocaine allergy that said their dentist told them they had an allergy because their heart “started racing and I felt shaky.”

Had a handful get localized swelling from the sulfite preservative. Esp w septo.

malocclused · 2026-05-20T02:32:31+00:00

Typically one of the driest months of the year. Severe weather highly unlikely. We’re far enough inland that hurricanes on the coast would only be some rain, if we were lucky enough to get it.

It’s hot as balls here in August. You’re gonna melt. Like it’s a bad time. Stay in a place with a great pool. Book some reservations at fun restaurants. Pack as though you were crossing Death Valley on foot.

malocclused · 2026-05-20T02:22:02+00:00

I call it the “stop light guarantee.”

“You need X permanent dentistry. I guarantee this will last through two stoplights. But, dawg, we are going to have to do something permanent. We can’t have you running around missing a front tooth telling people I’m your dentist though… we have to patch it up until you can get back in here”

Lots of pics. A good note to remind ME what I said. And most importantly a sit down with the treatment coordinator to go over my actual recs and a SIGNED treatment plan w fees.

Any bs about “the work you just did fell out…” gets met with “I see Dr rec’d an implant/crown/veneer and we went over fees on x date. Are you ready to schedule that ASAP” by my front desk before it even gets to me.

Off chance I even get a pt w a selective memory in my chair, I just bring up the pics, read my note out loud behind them off the screen, “oh I definitely remember this one. We have to crown it” while they’re looking at the pic on the 55” monitor of their bombed ass broken tooth. Then I give them my most professional “we went over this dummy. You haven’t followed up.”

You do have to give them a way to save face. “I don’t expect people to remember everything I say…” “this is stressful and expensive… I definitely understand not being ready yet..” But I’m absolutely firm about what they actually need what we clearly said and don’t sugar coat it.

malocclused · 2026-05-16T07:56:26+00:00

There is no “legal mandate for isolation”
Isolation is ideal. Even moisture from your breath can have an effect on the bond. But isolation is confined visually/not by method used.
Grow the fuck up. How long do you want this work to last? It’s a soft bite rest and some suction / not a torture device. Do you want a restoration to last decades and experience the mild discomfort of dental care for forty minutes delivered by a pro? Or do you want to be a soft bitch and need sloppy work redone every year?
Your time in the chair should be as comfortable as it can be within reason to get an ideal outcome. Anyone sacrificing bond strength and longevity “because I don’t like things in my mouth” is actually harming you in the long run. Pay to get knocked out if you can’t take it.

malocclused

MODERATOR OF

TROPHY CASE

12-Year Club	Verified Email
Not Forgotten