Metal-free Restorations


James Fondriest, DDS

I said goodbye to this patient almost a year ago. Terry had moved to Dallas, so I could not understand why she was on my schedule for an exam. I had done a fair amount of cosmetic dentistry for her when she lived in the Chicago area, including four anterior veneers, which she had received with much excitement. When she moved to Dallas, I gave her the name of a wonderful dentist who I respected greatly. I was confident of his ability to care for Terry.

During her examination, she asked me to do a porcelain crown for her on a lower first premolar. I asked if she had moved back to Chicago, and she said no; she had flown in only for this appointment. I asked if she had seen my doctor friend. Her answer was yes, but he wanted to do a gold crown. He told Terry that gold was the absolute best material he could use, and anything else would be a compromise. She felt he was old-fashioned and possibly not familiar with the latest materials. Terry wanted me to do a porcelain crown. The doctor I referred her to is a nationally recognized speaker, educator, and a dear friend. I know him to be a cutting- edge dentist, and, above all, ethical when making clinical decisions.

As a lecturer and teacher, I frequently am asked by other dentists to provide their dental care. In doing this, I have noticed that many of the dentists over 50 want gold work because they know it lasts longer. I often ask if they do much gold work on their patients, and the usual answer is “Not that much; I wish I did more. It is hard to sell.” These dentists have seen how forgiving gold can be occlusally and how long it lasts. That’s why they want it in their own mouths.

The patient’s point of view

Now let’s get back to my patient, Terry, and her preferences for her restorations. She told me that she was not going back to my Dallas friend, even though she firmly believed that he had a kind heart, a terrific skill level, and her best interests in mind. The reason? He didn’t listen and support her desire to have a natural-looking restoration. She didn’t feel heard. From her point of view, longevity was not as important as aesthetics. “He patronized me,” she commented, “because he thinks he knows more about me than I do. He was unwilling to give my priorities the same consideration he gave his own.”

So, what is optimal dentistry anyway? Is it always the work that will last the longest? Is it the prettiest? Is it whatever the patient wants? Over the years, my practice has suffered because of my use of amalgam and gold. I have found myself struggling to balance between pleasing the patient and holding out for what I feel is best for my patient. I am now sure there is a meeting place somewhere in the middle. I have given up on trying to push gold and amalgam. My practice has focused more on tooth-colored restorations in the last eight years, and I have benefited from it with an easily observed change in my client base. The new patients who seek me out are very aesthetic-conscious and are sophisticated in their choice of clothing and grooming. These patients are very interested in elective dentistry, and they want to know about their options.

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