> And it is alos far more easy on part
>of the dentist to place it because the techniques with
>composites makes dental life more difficult.

>>Summary of post below:
>>Amalgam is to be used mainly on poor people, and
>>especially if they have limited skills in English.

>Don't believe it. Amalgam is an excellent choice in many
>circumstances!

>Hans, I could be very {*filter*} rich just filling teeth that cosmetic
>dentists say cannot be filled. Well, some patients get the crown while
>other patients slink away until the tooth needs extracting. How else
>can you account for 34 million Americans with no teeth?

>> It should
>>also be used on regular Americans if you want to avoid
>>insurance hazzle.

>No hazzle. In fact, insurance won't allow inlays.

>> And it is alos far more easy on part
>>of the dentist to place it because the techniques with
>>composites makes dental life more difficult.

>True.

>I'd like to see a study on how many people are unhappy with
>composites. It is a percentage of the population from what I can tell.

>>On part of the dentist.
>>Nice post, Joel, you are getting more and more closer to
>>the practicalities  (not meant as sarcasm ... I think).
>>Michelangelo would have had a hard time chiseling marble
>>instead of working "al fresco" on the ceiling of the Sistine
>>Chapel since he was lying on his back when doing his master-
>>piece. Amalgam will never be a masterpiece, no matter how hard
>>you try.

>Not true. Amalgam is as good as the operator who installs it.

>> Even if you do all your amalgams lying on your back.

>That is one of the amazing things. A condensed amalgam stays put. A
>composite drips back out of those upper teeth!

>>>I could not unscrew this post
>>Probably a Dentatus that the previous dentists had screwed in !

>It was some weird one!

>>Bye for now,
>>Hans
>>============================================

>>>Body piercing, the IRS, and Michelangelo

>>>This makes a very serious case for amalgam usage.

>>>A patient of mine brought her mother over to the dental
>>>office with a certain tooth problem.  The mother could not
>>>understand or speak one single word of English.  The
>>>daughter herself has very limited English skills.

>>>"How much to fix this tooth?" they asked.

>>>"Let's look," I answered.

>>>There in sight was an upper left molar with the palatal and
>>>distal surface completely gone, and broken right down to the
>>>root.  There was also a broken composite filling in the top
>>>section of the tooth.  A nifty post had been inserted into
>>>the palatal root, but alas, it was now bent out at a right
>>>angle to the long axis of the tooth.

>>>In other words, it looked like a miniature version of one of
>>>those neat lever handles that people sometimes install on the
>>>doors of their houses. Those are the ones replacing the round
>>>doorknobs that give the house a bit of a colonial appearance.
>>>This tooth post also swung back and forth just like the lever
>>>door handles.

>>>I could not unscrew this post, and hardly even tried. What I
>>>did do was to power up my air turbine and zing through it
>>>just like a hot knife zings through a stick of softened
>>>butter.  I also zinged out that old composite using a huge,
>>>serrated diamond cylinder drill.  Nnyarrowww, nnyarowww,
>>>nnyarroww.  You get the picture here, I am sure. I widened
>>>first, then I deepened the occlusal portion of the cavity
>>>preparation and I widened the isthmus too. It was now
>>>designed and engineered to properly retain the filling.

>>>Next, I applied a matrix band and I took out some of my huge
>>>condensers that I keep around especially for this purpose.
>>>They look much too big for human teeth! In fact they are too
>>>big for normal teeth with normal cavities. I filled that
>>>tooth right up with a nice, dense, well-condensed amalgam.

>>>Now I could have used composite I guess, but composite is
>>>what failed for this patient the last time around. I am not
>>>sure if it was the materials or if the problem was how it was
>>>placed, but restoring this tooth with composite might be
>>>pushing the envelope.

>>>Quite honestly, I have done some huge composite build-ups in
>>>my day too, if only to see for myself how durable the stuff
>>>really is. However, I have not done nearly enough to have
>>>complete confidence in this material.  Amalgam, by contrast,
>>>is very very sturdy. A properly placed amalgam is not going
>>>to crack anytime soon.

>>>A second advantage with amalgam is that I am working "al
>>>fresco." This means I am "working in fresh plaster," so to
>>>speak.  With composite, you are not working "al fresco."

>>>Michelangelo and those guys were the masters of this
>>>technique.  First, they would eat their lunch, then they'd
>>>clean up, and afterwards they would put up a whole section of
>>>wet plaster.  They would put up about as much as they thought
>>>they could complete before the plaster set.

>>>Then they went to work on it in earnest.  Slowly, slowly,
>>>they applied the color while the plaster was still wet.  A
>>>little more blue, a little less green, they would work
>>>quickly and efficiently. This was do-able as the wet surface
>>>allowed you to practice your artwork.

>>>This is why you eat your lunch first. If you have to
>>>interrupt your work in the middle to grab a quick bite,
>>>you'll come back to find out that the darned stuff has
>>>already set up. Now it is too late to fix up the wall.  I
>>>guess if it is the Sistine Chapel, the Pope might get pretty
>>>mad at you too.  In the dental office, it is certainly less
>>>critical.

>>>However, this is also the case with amalgam. I like to use
>>>the sides of the tooth, the height of the adjacent teeth, the
>>>slope of the cusps, etc, to fashion a most pleasing contour.
>>>Next, the patient is instructed to bite very lightly. VERY
>>>lightly.  From this I can pretty accurately judge the point
>>>of contact.  Carve, carve, carve, bite again. Carve, carve,
>>>carve.

>>>From that point, I can expertly carve in a valley here, an
>>>accessory groove there, all very quickly, and all very
>>>nicely.  Remember, I already mentioned that I am working "al
>>>fresco." I do not stop for my lunch in the middle either.  I
>>>already mentioned the part about the Pope.

>>>With composite, once you hit the restoration with the curing
>>>light, it is completely hard.  Completely! This is NOT "al
>>>fresco" at all. It is the opposite.  I guess that it could be
>>>called "al cruncho."

>>>To get everything to the right height and contour takes
>>>considerably longer.  First off, you are working with rotary
>>>instruments instead of with those nifty carvers.  You are now
>>>using diamonds and carbides.  You are basically grinding into
>>>the restoration to correct the occlusion.  This is more like
>>>Michelangelo chiseling marble instead of working away "al
>>>fresco" on the ceiling of the Sistine Chapel.

>>>I do not like to see a complete flattening off the tooth
>>>(yikes! no anatomy) either, so this takes me quite a while
>>>longer in the circumstance of a huge restoration.  I could
>>>flatten it. But I don't care to. Remember, just like that
>>>Sistine Chapel ceiling, I have to continue looking at this
>>>thing for many years to come! And the Pope has got to look at
>>>it too.

>>>When I told this patient how much money, did I add up all of
>>>the surfaces and all of the materials that I thought I'd
>>>need?  Absolutely not.  There's no need to. I can judge
>>>pretty much how long this job will take.  That is what
>>>matters most to me.  Its time.  That is the only non-
>>>replaceable commodity around here.

>>>I am sure that a strong case could be made for a crown
>>>lengthening, some scaling and root planing, and a post and
>>>crown. But hey! As I looked around the mouth, I sensed that
>>>this would not fly at all.  It would be like trying aviation
>>>before Kitty Hawk and the Wright brothers.

>>>Unfortunately, this is also the case with at least 30% of the
>>>American population.  You, the dentist, know many ways of
>>>fixing any one single tooth.  However, your patient might
>>>only have a simple extraction in mind!

>>>This lady just needed a bit of my help (a quick fix that is)
>>>to correct this annoying little swinging lever problem.
>>>Without some help, this tooth most certainly would have
>>>become lost.  It would have opened the door to more dental
>>>problems! Cool metaphor, eh?

>>>Now is this a dental service? I say it definitely is. Some of
>>>you may disagree with me. I doubt that these folks (language
>>>problem, remember) could be convinced even with a whole bunch
>>>of fancy words, and arm waving too, about the value of
>>>running up the dental bill into the thousands.

>>>Sometimes the words only get in our way. I knew what I had to
>>>do and that was really all that mattered.  You know, it was
>>>kind of gratifying too. Hey! That's dentistry. Or I should
>>>say that WAS dentistry.

>>>So what did this all cost? Far less than you would imagine.
>>>After all, there were no insurance companies to deny or
>>>to approve my claim, no waiting around for the mailman with
>>>the check, and no accountants poring over the books either.

>>>It was a simple payment for a small repair. What could be
>>>better?  It just points out to me how dental insurers,
>>>replete with their rules and regulations have almost ruined
>>>the practice of dentistry for half of the population.  Only
>>>fluoride has saved them.

>>>I recalled another guy, a very nice patient, who had either
>>>abrasion or abfraction lesions near the gum line of several
>>>upper teeth. These were on the {*filter*} surfaces of an upper
>>>molar and an upper bicuspid.  Of course, I used what is best
>>>- that was composite in this case.  Amalgam, with its
>>>distinct requirements for mechanical retention, would have
>>>clearly endangered the pulps and nerves of the teeth.

>>>The insurance company, Delta of California, DDP*Delta
>>>promptly sent back the transmittal with some very bad news.
>>>It stated,

>>>"No payment for composites on posterior teeth.  This service
>>>is the patient's responsibility."

>>>Now please recall that this patient IS ALREADY paying for
>>>dental care through his dental premiums. What do I tell him
>>>now?

>>>Well, he is a very good guy and I also just completed twelve
>>>units of bridgework for him very recently. So I just threw
>>>that {*filter*} piece of paper right into the trash without a
>>>second thought about it.

>>>Supposing another guy comes in with the same insurance and
>>>the same cavity, but without the need for the 12 units of
>>>bridgework?  Do you see how this puts the dentist right in
>>>the middle? The assumption here is that the dentist does not
>>>know how to extract the necessary money from the insurance
>>>company.

>>>By the way, this is not correct.  I am very good with
>>>extractions.

>>>What it leads to are diagnoses that are not necessarily in
>>>the patient's best interest. Another very reasonable
>>>alternative solution could be suggesting two additional
>>>crowns, possibly with root canals thrown in for some good
>>>measure.  That is not at all unreasonable.

>>>This diagnosis is always more difficult for the insurance
>>>company to argue with, especially since they are only looking
>>>at two-dimensional x-rays. But in any event, it may not be as
>>>good for the patient.

>>>Does this happen? Of course it does. Does it happen often?
>>>You bet it does.

>>>A second pet peeve of mine is where the insurance company (1)
>>>deducts $50 right from the get-go, or (2) sends the
>>>reimbur{*filter*}t check directly to the employee rather than to
>>>the dentist. This is technically known as "failing to honor
>>>an assignment of benefits."

>>>A formerly very good patient with excellent dental insurance
>>>found that there was suddenly a $50 deductible (per year)
>>>exclusion imposed on his dental insurance. Guess who has been
>>>ducking the dentist for the past two years? He is still my
>>>patient. I see him at Wawa from time to time and his wife
>>>comes over here faithfully.

>>>About sending the check to the patient.

>>>Remember, the IRS has initially allowed employers to deduct
>>>the premiums as ERISA benefits.  As such, they are not
>>>subject to income taxation, FICA, etc.  They are technically,
>>>employee benefits.

>>>If the insurance company then sends the benefits check to the
>>>worker, then at the very least, the IRS should require
>>>government notification from insurance carriers to the IRS of
>>>patient payment through a 1099 document.  If the patient
>>>claims no taxes are due, then the patient should also be
>>>required to establish that he/she has indeed forwarded the
>>>check to the health care provider.

>>>If the patient has failed to forward the benefit check to the
>>>health care provider, then they should be held accountable
>>>for any unpaid income tax. Failing that, they should be
>>>prosecuted for tax evasion, which is exactly what it is.  In
>>>fact, they have converted what was a health care benefit into
>>>their own tax-free income.

>>>I would also suggest a mandatory 6-month prison sentence be
>>>imposed upon conviction of this crime. Maybe we'd have to
>>>build a few more prisons, or alternatively, we could release
>>>some of the {*filter*}ers and rapists instead. We'd be much safer
>>>now that the real bad guys are locked up.  Several lawyers
>>>have also suggested property forfeiture through RICO laws.

>>>By contrast, here is United Concordia. In exchange for
>>>sending me the check directly with no fooling around at all,
>>>I have signed a contract with them to accept their allowance
>>>as payment in full. Well, okay.

>>>Q1120 "As a Participating Provider, you have agreed to accept
>>>the allowance as full payment for covered services."

>>>How much? Well it just depends.

>>>Here is one case, a straight forward deal, a decent patient
>>>for whom I constructed a lower partial denture. This
>>>consisted of acrylic attachments plus a cast stainess steel
>>>base.  What is the allowance?

>>>D5214 - Lower partial ---- $494.
>>>United Concordia sends me half --- $247.
>>>The patient pays me half too.

>>>Fair enough!

>>>  **

>>>We are overloaded with information in this information age,
>>>while we are simultaneously underwhelmed with knowledge.
>>>Using a touch-tone phone, we can track any dental claim for
>>>any service with just about any dental insurance company.
>>>That way, they cut way back on their need for live people. We
>>>just punch away at phones to our heart's content.

>>>Three weeks ago, we had traced a certain dental claim for
>>>$85 (date of service: 4/21/2000) and found out that it was
>>>paid on 5/24/2000 with check number 10496431.  Not bad so
>>>far.  That is information.  That comes very cheap in a touch-
>>>tone-activated, computerized world.

>>>Here is the little piece of missing knowledge:

>>>If you guys paid the claim, just where is the money anyway?

>>>6/15/2000

>>>Where is it? Ahhhhah!

>>>They sent it to a wrong address! I am certain it was opened,
>>>stamped and already 'accidentally' deposited by now. "We will
>>>issue a new check. We will stop payment on the old check!"

>>>I have been trying to get this same insurance company to
>>>change my address for over three years now. They won't do it.
>>>Do you see what I mean when I tell you that a quick deal
>>>involving the 'coin of the realm' is still much preferred?

>>>Thinking back, this jogs my memory. I had another claim from
>>>this same company several years back. It involved my having
>>>to have notarized three separate forms (cost me eight bucks
>>>too!) and it took over eigh{*filter*} months until they would send
>>>me a replacement check for $155. Oh Jeez, I hope we are not
>>>going there again!  (See ** ADDENDUM below).

>>>Here is a second pre-treatment determination that has gone
>>>completely astray - back and forth already so much that I am
>>>starting to even like the Billy Joel Piano Man music that
>>>they always broadcast across our speaker phone. That's one of
>>>the perks of this new computer information age!

>>>Here is the little piece of missing knowledge:

>>>Do you think the employee will still be working at his same
>>>job (and still covered by your dental insurance) by the time
>>>you guys decide to give me the approval?

>>>Customer Service: "We are so sorry. It is our mistake."

>>>Organized dentistry should have become involved with many of
>>>these inequities a very long time ago. Unfortunately the
>>>American Dental Association's abbreviation is not really ADA.
>>>Its actually spelled more like W-U-S-S.

>>>Now you might be wondering, "Why did Michelangelo have to
>>>clean up before laying down the plaster?"

>>>You will recall I said,

>>>"Michelangelo and those guys were the masters of this
>>>technique.  First, they would eat their lunch, then they'd
>>>clean up, and afterwards they would put up a whole section of
>>>wet plaster."

>>>You see, the first few times out, Michelangelo's assistants
>>>got some hunks of salami, a few slices of pastrami, a little
>>>mustard and some of the rye bread caught up inside the
>>>fresco. When Michelangelo saw it, he went completely nuts.

>>>However, in later years, this technique caught on Big Time.

>>>"Blue Poles," by the abstract expressionist artist, Jackson
>>>Pollack last sold at Sothby's for upwards of tens of
>>>millions.  Few people notice that it still has some of the
>>>original pastrami and rye bread stuck right in the middle of
>>>it.

>>>There was another piece where Jackson was eating a tongue
>>>sandwich. Part of the tongue (not Pollack's tongue) got
>>>caught in the collage.  I have already posted this story at
>>>rec.alt.bodymodification.  They just loved it over there.
>>>They simply love any kind of story that involves tongues.

>>>Cheers,

>>>Joel M. Eichen, D.D.S.

>>>PS to RABbits:

>>>That's rec.alt.bodyslicers.

>>>The purpose of these posts is (1) to illustrate some simple
>>>common-sense principles about dentistry, (2) to take a couple
>>>of pot-shots at the dental insurance industry, and (3) to get
>>>some discussions going.  It is also meant (4) to amuse
>>>somewhat, however this is sometimes a stretch.

>>>Thanks for helping out anyway.

>>>Body piercing and {*filter*}piercing? I could care less. It really
>>>does not affect me, not even one single bit. Trust me on
>>>that. I am not that interested. Well, wait a minute, come to
>>>think of it .  .  .

>>>But thanks for being good sports and joining in with our very
>>>lively dental discussion group.  I know that "lively dental
>>>discussions" sounds like an oxymoron.  Don't worry.  Perhaps
>>>you'll help spread the word that this is really the place to
>>>come for some really GOOD dental advice!

>>>Did my little scheme work? Of course it did! Look at how many
>>>of you guys are reading this post right now!  Remember that
>>>with all things, that he who laughs last, laughs last.

>>>Sorry for all of the brouhaha that I got you guys got in so
>>>deep over.  Brouhaha?  Yeh that's like having a brewski or
>>>two and telling a few jokes . . . I guess.

>>>~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

>>>** Addendum

>>>Joel M. Eichen, D.D.S.
>>>XXXXXXXXXXXXXXX

>>>Ms. XXX
>>>XXXXXXXXXXXXXXXXX

>>>July 20, 1998

>>>Dear Ms. XXX,

>>>This will confirm our conversations of
>>>12/27/97 where you mentioned that you have
>>>received my notarized affidavits for the
>>>missing check #64167267 endorsed by some
>>>unknown person.

>>>You had also told me on 4/21/98 that you would
>>>check on the progress of a replacement check.

>>>I spoke with you on 6/2/98 and you said that
>>>you would get back to me. I have not heard
>>>from you.

>>>You have contacted me after my last letter on
>>>June 10, 1998.

>>>You mentioned that your "fraud department" was
>>>working on this. Can you send me name and number
>>>of someone in that department so that I can
>>>contact them directly and proceed with this matter.

>>>Sincerely,

>>>Joel M. Eichen, D.D.S.

>>>~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

>>>[old post]

>>>Bum Check

>>>This is one of my most egregious cases of getting "ripped
>>>off" and its a pretty good example of why dentistry is
>>>getting mighty expensive!

>>>I'd like to share it with you.

>>>In March 1997, I was issued an insurance check for $155 as
>>>payment for something or other. When we inquired about some
>>>patient's outstanding bill, the issuing insurance company
>>>referred me to that check.

>>>Who? What check?

>>>Turns out it was endorsed by someone else. Who? I don't know.
>>>Its still a mystery. The handwriting is Eastern European, but
>>>I don't know where this check was deposited or how they got
>>>hold of it.  This is the banking industry's problem, not the
>>>dental office's problem.

>>>So, in December, 1997 I filled out the necessary affidavits
>>>and spent another $8 having them notarized. Now I got eight
>>>bucks invested so I can't even forget about it any more even
>>>if I want to.  Its now the middle of June, 1998 and the
>>>insurance company's fraud department is still "working on
>>>it."

>>>Makes you kind of wonder, doesn't it?  They work at two
>>>speeds over there: (1) slow and (2) stop.

>>>  **

>>>We are almost down to the bottom of the page. That is, if
>>>anyone is still reading! Almost every line of the post is
>>>about people -- its about dentists and their patients --
>>>treating one another sometimes fairly and other times not so
>>>fairly.

>>>I suppose that some young people look around them and they
>>>see all of this nonsense. Meanwhile, they are thinking to
>>>themselves, "How will I ever be able to make my way in this
>>>world?  It seems impossible.  And come to think of it, do I
>>>really want to?"

>>>So what do they do?

>>>Well, they join a brotherhood or pledge themselves to a
>>>sisterhood where they irrevokably cut themselves off from
>>>competing in this stuffy, trashy establishment world. Well,
>>>my friends, green hair still grows out.  Those Mohawks still
>>>grow back.  But just place a few pieces of metal in your
>>>face, and you are clearly making an impressionable statement!

>>>Does that make any sense to anyone?  Ahh, what an exciting
>>>journey it has been so far! So many things learned along the
>>>way and so many things still to improve. Where do we begin?
>>>What do we start?

>>>Start with what?

>>>Making for ourselves, a brand new, "Brave New World." A brand
>>>new "Shangi-La."  What's my method? first, I get your
>>>attention! Its harder than it appears.

>>>Cheers,

>>>Joel

>>>Joel M. Eichen, D.D.S.