• Welcome! This is a forum for anyone who is affected by a fear of the dentist, dental phobia, or specific dental fears.

    We are lucky to count a number of dentists among our members and moderators. Look out for the "Verified dentist" badges. If you are a dental professional who likes to help, please join our community!

    Register now to access many more features and forums!

Dentists guidelines for replacing fillings....

P

Poppy1234

taking a break from the forum
Joined
Aug 13, 2010
Messages
303
Location
Sheffield and Stockport, UK.
I've been corresponding with a dentist in America, (researching for a community radio show I'm doing on preventing tooth decay) and he told me the average life of silver fillings in the USA is just 7 - 8 years.
I told him mine have lasted 35 years, and most people in the UK report a similar length of time for them to last, and even longer.
It's got him thinking!!
He's helped me a lot, and so I wanted to ask his question on here for him, as I'm interested too...

So....are dentists in the USA too keen to replace perfectly good fillings just for the money??
What are the guidelines for UK NHS and private dentists for replacing fillings??
Only when they break? Or when they are deemed to be getting thin??
He asks........

I have been thinking a lot about your fillings lasting 35 years. I wonder, because a lot of what I write is based on tons of research showing average lifespan of fillings is much lower than you report. I also have corresponded with another person from England who reported their filling longevity similar to yours.

The only difference I can think of is the possibility that US dentists are making the judgement of when to replace fillings differently than dentists in England.

I have no idea how dentists in the National Health Service in England paid for fillings and what kind of limitations are placed. In other words I'm wondering if the incentives are different in England from those in the US.

I can't find out how it works there, but I would appreciate any information you might be able to pass on about this. I really am curious to know if the average life of fillings could be so different because of this. The cost over a lifetime is tremendously higher with a shorter lifespan for each filling.

I hope you can find out for me.


Can you help him??? :confused:
 
brit

brit

Super Moderator
Staff member
Joined
Mar 23, 2006
Messages
6,990
Location
In My Dental Happy Place
I reckon a lot of the USA ones are in it for the money because of the way the system is set up there. There are also the massive cosmetic pressures there to change because of aesthetics....all dentists I have ever seen in UK (NHS and private), EU countries and other places in the world have been against changing amalgams unnecessarily.

I don't know whether NHS ones placed today will last as well as mine from 1970s..heck even my Mum's from 1960s have held up well too and my sister's from 1980s.

Everytime you drill into a tooth you insult it, I think USA dentists if they have replaced amalgams when not failing, have made it more likely that that tooth will eventually need a root canal, then a crown, then an extraction and implant..or if you are poor..dentures.....it's a perpetuating cycle.

I know one marketing ploy which is used is that amalgams should be replaced for composite because amalgam expands and eventually leads to cracks in the tooth; or look there are cracks in the tooth from the amalgam, we'd better crown it to strengthen it. The process of sheering off tooth structure to do a crown can lead to a root canal being needed.....

The 1970s 'drill and fill' fillings were paid for on a 'piece rate' basis so there was every financial incentive to fill teeth, which means there would be every incentive to re-do them as well but that's the bit that doesn't seem to happen so much...maybe because of ethics???
Under current NHS payment system in England and Wales, there is more of an incentive to do as little as possible as there are fixed bands for courses of treatment regardless of how much work they find to do...but that's not the issue because we are talking about fillings placed years ago under the 'piece rate' system.

I like you Poppy do wonder if all my molars needed the fillings they got because remarkably it's mainly only the molars which got the amalgams as if everyone got those all filled and then they left you alone lol and moved on to your siblings...(sorry just cynically speculating - I'm sure some were needed).

Maybe some USA dentists do fillings to a deliberately lower standard so it fails within 10 years and brings them repeat business....a bit like manufactured goods don't seem to last as long as they used to...just guessing....and fear of litigation could be it also, best not say it will last 30 years as you might be sued if it doesn't.
 
S

Stress Doc

Account Closed
Joined
Dec 10, 2008
Messages
788
Our office only replaces them if they are leaking or cracked. In the USA the old standard was very large fillings which did compromise tooth structure.

Many of these fillings were replaced for cosmetic reasons and from the FDA stance on mercury fillings.

We will not replace a filling that does not need it as, in our opinion, this is not ethical. The standards of care have changed greatly over the years and many things that were once done have been abandoned. We say that a composite filling will last between 5-15 years depending upon depth, tooth, surface area and bite alignment. We do not do silver fillings. I had several silver fillings done in the 1960's and they lasted until 2007, about 43 years. The teeth did cracked and I had them crowned.

Most dentist here use digital Xrays, 50-80% less radiation. Laser drills are starting to appear and most gum surgery is done with lasers. Neuro-muscular (K7) work is becoming popular for correct bite alignment and dentist are being trained in sleep apnea work.

I enjoy working in a high tech office and constantly learning about new procedures and techniques as this is not in my discipline. My dental education has grown and this enables me to better serve our guests. Yes, we do not have patients, we have guests.

Dentistry is expensive here, and can be very expensive. The cost of education and equipment keeps going up and mal-practice insurance is also costly. I do not know how successful the implementation of a public health care system will be here and it is many years in the future.
 
P

Poppy1234

taking a break from the forum
Joined
Aug 13, 2010
Messages
303
Location
Sheffield and Stockport, UK.
Great responses. Thanks to you both. I shall pass this onto him.
He's certainly very interested in all this!
He's just asked this...if you have anything further to add....


I want you to know that each time a filling is replaced the hole must be drilled bigger. After a certain number of replacements there is not enough tooth left to hold a filling. At this time a much more expensive "crown" must be made for the tooth. Often times a root canal treatment is also needed for this tooth.

In an important study done in the US it was shown that this lifetime of breakdown and repair costs on average $2000 per tooth filled. That's in constant dollars. Assuming a low rate of inflation, the cost on average per tooth over a lifetime is $10,000.

If you are a person of means, that would mean some inconvenience and annoying time and expense. But people think that's life. But for a person counting his pennies it means a lifetime of dental pain, misery, embarrassment, and perhaps eventual loss of teeth. This study was done using US figures of filling longevity. As you might guess, those lifetime figures would be much lower where the fillings last longer.

That's why I'm anxious for someone to tell me if there is anything in the dental compensation system that would incentivise your British dentists to replace fillings less often than in the US where the dentist gets paid more for replacing a filling more often.

If fillings were made to last 35 years each in this country I could stop being so obsessive compulsive about avoiding that first filling in a persons tooth.

Can you find out if it has anything to do with the compensation question?
 
S

Stress Doc

Account Closed
Joined
Dec 10, 2008
Messages
788
Interesting. I would like to see the USA study as I am not familiar with it.
Can you obtain an abstract or source reference?
 
D

decan

Well-known member
Joined
Sep 4, 2010
Messages
404
Location
USA
I would like to see the data that says an amalgam filling lasts only 5-7 years...I'm replacing a few amalgam fillings in a guy that has had them for 53 years and they are just now starting to fail.
 
brit

brit

Super Moderator
Staff member
Joined
Mar 23, 2006
Messages
6,990
Location
In My Dental Happy Place
So the question is why does he say amalgams have such a short lifespan on average in USA. I think I found that figure on a website once when googling and was very very surprised because it doesn't reflect my personal experiences.

Here's the website: http://www.colgate.com/app/Colgate/...ckupsDentProc/Fillings/FillingsTheBasics.cvsp

Seems weird to me and inaccurate - 5-7 max 15 for amalgams lol and it states composite is even less. I have a composite over an rct which was not crowned (wasn't considered necessary by UK private dentist) which has lasted 18 years so far.

I've just had another thought....when Stressdoc had his long-lasting amalgams placed the dentist would likely have been working to the UK model of the dentist spending the whole appt time with the patient and very little would have been delegated to Assistants. This is still largely true for UK does this mean that the 'working too intensively' and 'flitting from patient to patient" in search of daily production has a detrimental effect on work quality with the constant breaks in dentist's concentration?

Also the issue of whether anything placed by an Assistant compromises quality...it's all very well to say the filling material placed by an assistant has been checked by the dentist but that's not the same thing as it being placed expertly by the dentist...to me it isn't anyway. I remember dentists mixing up their own filling stuff in front of me...they did it themselves...I must admit I occasionally wonder when Assistant has prepared sth, what if she was thinking about last night's tv when mixing that and the ingredients are in the wrong proportions..it's all about chemistry like baking a cake...this could lead to earlier failure maybe?

BTW Stressdoc and I are not dentists....Decan?
Gordon is the one who would actually know what NHS guidelines have been over the years. It was definitely piece-rate until latest contract and maybe the explanation is that NHS dentists were rarely short of patients so there was no need to overtreat...even check-ups were free in 1970s so most of the 40% population registered with an NHS dentist (was there any other kind back then not really only on Wimpole Street) would usually come along every 6 months for a check-up. They'd do a scrape and polish (very quick one) at the check-up and if no work was needed there was no bill - x-rays were only done occasionally and non-exempt adults had to pay for those. Even now in NHS I think these are seen as sth which should not be done routinely (get the impression some USA dentists insist on them before they have even seen patients) - views on this may change as the digital x-rays become safer.
 
Last edited:
brit

brit

Super Moderator
Staff member
Joined
Mar 23, 2006
Messages
6,990
Location
In My Dental Happy Place
In an important study done in the US it was shown that this lifetime of breakdown and repair costs on average $2000 per tooth filled. That's in constant dollars. Assuming a low rate of inflation, the cost on average per tooth over a lifetime is $10,000.
[/I]
It's a good point but if we accept that having a filling starts off the cycle of inevitable repair at some point..even if not until 40 years later...it means people should be aware of this so they can make financial provision for later years (I have my implant fund earmarked lol).
This is necessary in UK as well since the NHS would only provide dentures once the root canals and crowns have failed and sometimes the root canals would not be available depending on dentist's inclinations...skill levels for crowns and root canals would vary widely. SO if you want implants or implant-supported dentures you have to find the money yourself.

How long does anyone reckon those Extreme Makeover smiles last? I'm always horrified to see the tooth reduction which is then placed over by a 'long strip of plastic' which becomes the person's teeth....what guarantee would they get 10 years? Let's hope they have the money for the inevitable replacement work when the TV crew is long gone.
All dental work fails eventually as they say. Prevention is key.
 
S

Stress Doc

Account Closed
Joined
Dec 10, 2008
Messages
788
I have not seen an assistant have anything to do with fillings other than suction and handing tools. It is true about Xrays. We have them done on every patient before they are seen by the dentist. Our routine is as follows

Xrays, mouth and face photos (20 minutes)
Dentist looks at Xrays and does visual exam and screenings (45-60 minutes)
Treatment options discussed (30 minutes)
Appointments booked and treatment

A first visit is usually booked for 1 1/2- 2 hours. No treatment is done during this visit.

We are less production than most but do have some long days.
 
D

decan

Well-known member
Joined
Sep 4, 2010
Messages
404
Location
USA
I'm a third year dental student so not a dentist (yet). ;)

Here is an abstract I found from the journal of dental research:

Information about the long-term clinical survival of large amalgam and composite restorations is still lacking. This retrospective study compares the longevity of three- and four-/five-surface amalgam and composite restorations relative to patients’ caries risk. Patient records from a general practice were used for data collection. We evaluated 1949 large class II restorations (1202 amalgam/747 composite). Dates of placement, replacement, and failure were recorded, and caries risk of patients was assessed. Survival was calculated from Kaplan-Meier statistics. After 12 years, 293 amalgam and 114 composite restorations had failed. Large composite restorations showed a higher survival in the combined population and in the low-risk group. For three-surface restorations in high-risk patients, amalgam showed better survival.

J Dent Res. 2010 Oct;89(10):1063-7. Epub 2010 Jul 26.
12-year survival of composite vs. amalgam restorations.
Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC.

From what we've been taught amalgam works better in the posterior teeth but composites are getting better, which is why you're seeing them more often in practice.

As far as x-rays...I feel like they are a necessary tool. A full mouth series of x rays is standard for a new patient (unless they bring recent xrays with them) so you can properly assess the current oral condition. Its not possible to diagnose a patient properly without appropriate xrays.
 
Last edited:
P

Poppy1234

taking a break from the forum
Joined
Aug 13, 2010
Messages
303
Location
Sheffield and Stockport, UK.
Cheers.
I'll keep passing everything onto him!

I personally have never paid a penny restoring, or even getting fillings!
Though I understand how passionately he feels that no filling should be done unless absolutely necessary.
I feel if we go to the dentist every 6 months, then ANY decay should be seen BEFORE it becomes a cavity, so we can reverse it. (Which is why I'm furious I had a dentist that didn't know what decay was UNTIL it became a cavity...:mad:)

All 5 of mine were done free on the NHS and haven't ever come loose or come out.
So I've asked him whether these American fillings are actually falling out after 7 years, or if their dentists are recommending they be replaced....??
 
brit

brit

Super Moderator
Staff member
Joined
Mar 23, 2006
Messages
6,990
Location
In My Dental Happy Place
As far as x-rays...I feel like they are a necessary tool. A full mouth series of x rays is standard for a new patient (unless they bring recent xrays with them) so you can properly assess the current oral condition. Its not possible to diagnose a patient properly without appropriate xrays.
I accept that is what you are taught. How many are involved in a full mouth series? When I was last a new patient I had several taken but not up to 16 I have heard mentioned on here.
I would agree for a new patient, you should be taking x-rays...but what about at future check-ups....that's what I was referring to.
UK NHS(1970s) maybe took them on me as a teenager once a year but as an adult far less. MY first UK private dentist was against taking them unless absolutely necessary (even though he could have charged me!)...it seems we have more fear of radiation effects on this side of the pond. I think the GDC has strong views on not overusing X-rays as well...I think the dentist is supposed to examine patient and then decide they are appropriate (may be true in some USA states as well).

Your (legitimate) fear of being sued if sth goes wrong with the tooth subsequently and no x-rays were taken probably drives this approach as well.
 
P

Poppy1234

taking a break from the forum
Joined
Aug 13, 2010
Messages
303
Location
Sheffield and Stockport, UK.
I didn't know there was such a thing as teeth x-rays until 2001...
I'd gone every 6 months all my life, yet never knew such a thing existed until a few years ago...Good old NHS....:mad:
 
D

decan

Well-known member
Joined
Sep 4, 2010
Messages
404
Location
USA
At our school its all based on a selection criteria...if someone has 6 teeth in their mouth we'll obviously take much fewer films. If someone has a completely bombed out mouth and we know it'll require full mouth extractions followed by complete dentures, we take a pano and call it a day. For most (those who have all their teeth) a full mouth series consists of 20 films. After this we generally take bitewings (usually 4 films) on a yearly basis to keep track of decay. Like you said, you have to examine the patient and see what films are appropriate.

Note: this is the protocol for adults...the protocol for kids is different.
 
Last edited:
P

Poppy1234

taking a break from the forum
Joined
Aug 13, 2010
Messages
303
Location
Sheffield and Stockport, UK.
I have not seen an assistant have anything to do with fillings other than suction and handing tools. It is true about Xrays. We have them done on every patient before they are seen by the dentist. Our routine is as follows

Xrays, mouth and face photos (20 minutes)
Dentist looks at Xrays and does visual exam and screenings (45-60 minutes)
Treatment options discussed (30 minutes)
Appointments booked and treatment

A first visit is usually booked for 1 1/2- 2 hours. No treatment is done during this visit.

We are less production than most but do have some long days.
Blimey! The NHS give you ten minutes for your first check-up as a new patient.....:mad: You get a very quick glance, and x-rays if you're lucky...
I got 30 mins going private.....
 
brit

brit

Super Moderator
Staff member
Joined
Mar 23, 2006
Messages
6,990
Location
In My Dental Happy Place
Blimey! The NHS give you ten minutes for your first check-up as a new patient.....:mad: You get a very quick glance, and x-rays if you're lucky...
I got 30 mins going private.....
It used to be much longer than 10 mins in 1970s for new patients in my experience...my first check-up as a new patient back then lasted at least half an hour and lots of work was found.

The NHS slots now seem way too short and even a cursory cleaning isn't automatically included..I think the reason it wasn't so rushed when I was say a teenager was because many more people were afraid of the dentist and so the demand wasn't as high as it is now.
They've always had x-rays available except maybe my dentist in 1960s didn't. But then my 1960s surgery looked like the one on display for the 1930s in the Science Museum in London...say no more..hardly state of the art.
The main ones who took lots of x-rays were NHS orthodontists which again makes sense.
It seems you got the rough end of the NHS offering Poppy including the no numbing gel etc etc.
 
Last edited:
brit

brit

Super Moderator
Staff member
Joined
Mar 23, 2006
Messages
6,990
Location
In My Dental Happy Place
Blimey! The NHS give you ten minutes for your first check-up as a new patient.....:mad: You get a very quick glance, and x-rays if you're lucky...
I got 30 mins going private.....
But that's why it costs 50-100 pounds privately and not 15 pounds/free on NHS. To me it is well worth paying more for TLC and time to chat and build up a relationship of trust.
 
P

Poppy1234

taking a break from the forum
Joined
Aug 13, 2010
Messages
303
Location
Sheffield and Stockport, UK.
It used to be much longer than 10 mins in 1970s for new patients in my experience...my first check-up as a new patient back then lasted at least half an hour and lots of work was found.

The NHS slots now seem way too short and even a cursory cleaning isn't automatically included..I think the reason it wasn't so rushed when I was say a teenager was because many more people were afraid of the dentist and so the demand wasn't as high as it is now.
They've always had x-rays available except maybe my dentist in 1960s didn't. But then my 1960s surgery looked like the one on display for the 1930s in the Science Museum in London...say no more..hardly state of the art.
The main ones who took lots of x-rays were NHS orthodontists which again makes sense.
It seems you got the rough end of the NHS offering Poppy including the no numbing gel etc etc.
My NHS dentist refuses to clean them at all! Says they are too clean, though I can see clear areas that need cleaning.

I was astonished a few years ago when they mentioned x-rays.
Never heard of such a thing until then. Never got offered them before 2001.

Even my new private dentist doesn't do numbing unless you ask for it.
But how would you know to ask?
I'd never heard of such a thing until I found this site a month ago!
 
P

Poppy1234

taking a break from the forum
Joined
Aug 13, 2010
Messages
303
Location
Sheffield and Stockport, UK.
But that's why it costs 50-100 pounds privately and not 15 pounds/free on NHS. To me it is well worth paying more for TLC and time to chat and build up a relationship of trust.
I will always get a check-up privately now. Though I'd have to go NHS for treatment.
£66.50 for a tiny silver filling....I can get it free on the NHS.
Though I'd NEVER trust the NHS again for a check-up, as they simply cannot spot early decay, and allow cavities to form.
 
S

Stress Doc

Account Closed
Joined
Dec 10, 2008
Messages
788
I agree with Decan. Xrays are very basic to dental appointments here. The old Xrays produced a lot of radiation. The digital ones are much safer and quicker. Less than 5 minutes for a full set and no biting in the cardboard slides.


I cannot imagine a 10 minute appointment. It takes time to develop a relationship, have a through exam and explore options. Our office maybe a bit different but we are all about comfort and precision. If you are a scared or phobic guest we take time. Nervous guests spend an hour with me before the appointment to work through some fears and relax them. I am with them through the entire appointment and control the flow, make recommendations when needed. Our staff is very people oriented and kind. We call guests after every appointment and if you have work done on a Friday you will have our cell phone numbers for weekend concerns. Granted, this is not cheap but it seems to work.

If only 10 minutes are spent on an appointment it is easy to miss things. You would catch the big obvious things but could easily overlook the small things that do not warrant immediate attention. The focus would be more on fixing the big problems and overlooking things until they become problems. This is more of a disease based rather than a prevention based model. I almost thing it is inevitable with a public health system. Compromise is the order of the day. It becomes more triage than anything else.

Blessings :D
 
Top