I am sure the petitioner has good intension to protect the public from bad dentistry, but why only five years?  Why not ten, twenty or thirty?  I hate to see C&B failures, but I cannot be held accountable for all the failures I have seen in work of any age.  What C&B failure data does the Commonwealth have to suggest the need for a change?  I would be against any change to current rules since the factors causing early failure of C&B are multifactorial.  Who will judge what failures are related to patient host factors, which are related to material or laboratory issues, and which were dentist errors? In the early 1990 I did a bunch of Procera Alumina crown, many of them failed 8-9 years out.  I hated to see these fail but we were told by manufactures that these crowns worked and had lifetimes equivalent to PFMs.  They were wrong. 

 Are you asking dentist to be responsible for patient’s failure to seek routine dental care, or if they fail to practice proper oral hygiene?  What happens if the patient’s host oral flora changes due to hospitalization, diseases which lead to immunocompromised states, changes mental status or cognitive abilities, or accidents?  How about material failures or poor laboratory workmanship that only show up with time?  Will laboratory also be forced to warrantee their work, or will the burden just be borne by the dentist?  Medical doctors don’t give any warrantees if the surgery fails, cancer comes back or if a patient contracts a nosocomial infection which requires additional treatment and fees. We will be forced to increase our fees to cover this additional liability.

We currently have mechanisms to address patients complaints due to a lack of proper retention and resistance form, incomplete decay removal, bad workmanship and improper fix.  Patients can file a complaint with the BOD and an investigation will follow. We have all seen what we consider bad work, but in a court room these are just our opinions and do not represent the standard of care.

It should be left up to the individual dentist to determine his/her office policies.  If this were an appliance or electronic equipment the consumer would be allowed to buy an extended warrantee at their discretion.  I personally warrantee my work for five years when the C&B is fabricated in the USA and the lab generally covers the replacement crown.  When price is the only consideration and off-shore lab is used, we do not have any margins left to offer any warrantee, since those labs done offer one to us.  If you are interested in helping the public the BOD should determine what types of failures have occurred and which materials are involved.  Maybe a class-action law suit is in order.

Dag Zapatero, DDS, MAGD

How can you possibly make a dentist warranty crowns and bridges for 5 years? You don't require that insurance companies pay dentists whatever the work costs, but rather the state allows insurance companies to dictate to the practitioner the course of care through various forms of intimidation and pressure. Due to the recent changes in healthcare in America the Federal government is mandating total coverage without any protection of the practitioner which is giving all the power to the insurance companies - don't buy into the fallacy that the insurance companies care about their customers; which happen to be the Dentist's patients.

The practitioner is not the only party involved with a crown or a bridge - the lab, the insurance company, and the patient are also responsible for the longevity and quality of the work. It is an unfair burden to force only 1/4 of the responsible parties to extend a warranty on the work that all 4 are responsible for.  If you require a warranty then you must also require the insurance company to pay whatever the cost which will allow the practitioner to select the lab and the materials they want without fear of going bankrupt. Or the State would have to pass a law that says that patients have to pay the difference between reimbursement and actual cost so the Dentist can use the materials and labs they deem best.  How can the dentist ensure the patient follows instructions? Will the insurance companies pay for a redo? Are you going to force all labs doing business in Virginia to extend a warranty on their work as well, thus driving labs out of the state too?

Yes, the dentist's work is important and they are the only party in any procedure that has taken an oath to care for the patient. Neither the Labs, the insurance companies, nor the patient have taken an oath and dedicated their lives to Dentistry. Don't further burden the practitioners and further drive the quality Dentists out of Virginia.

I read this petition in disbelief.  As a general Dentist I am in awe of the one dimensional thinking that happens in our Capital. The idea that a 5 year warrantee on crown and bridge is in any way a method to protect patients is absurd.  How can I warrantee something that I have such limited control of?  Yes, I can follow through on my responsibilities to ensure that the procedure is done to the high standard that I and the extremely large majority of my fellow colleagues accomplish every day, but it is extremely naive to think that alone ensures the success of treatment. I cannot stop my patients from drinking Monster drinks and Red Bull. I cannot drag them to their prophy appointments, or floss for them. I cannot ensure that they are not immunocomprimised in anyway, or guarantee that their family physician does not prescribe medications that cause extreme xerostomia. Even great dentistry will fail given the right mix of circumstances.

Clinical studies on the longevity of dental restorations has shown that the two primary reasons for having to replace a restoration (crowns and bridges, fillings included) are new tooth decay that occurs in the remaining tooth under the restoration, and fracture of the restoration.  Fractures tend to take place earlier in the life of the restoration and new tooth decay tends to occur later in the life of the restoration.  Tooth decay is the main reason for having to replace a dental restoration with fracture a distance second reason.  Tooth decay in a restored tooth is not something the dentists can control since it depends on risk factors that exist in the patient such as past history of tooth decay, strength of the bacteria present in the mouth, dietary use of sugars, saliva amount and content, oral hygiene practices, and use of fluoride toothpaste and rinses.  Dentists should talk to patients about these risk factors prior to restoring teeth or replacing missing teeth with bridges so the patient can make an informed decision to proceed with the restorations but there is no way to predict or guarantee when or if the restored tooth may develop new tooth decay.

I have published two review papers that looked at the scientific literature related to the relationship between the fit of restorations to the teeth and the risk of tooth decay.  The science does not support a relationship.  Dentist should stirve to make well fitting restorations but a poor fit does cause tooth decay.  Tooth decay is caused  by the factors I listed above and cannot be attributed to a poorly fitting restoration. 

Fracture of restorations tends to occur more frequently in some patients than others and this risk factors are bite forces and tooth clenching and grinding habits.  Certainly the early failure of a restoration due to fracture in a patient without these factors and without a history of breaking restorations, can indicated some problem with manufacture or design of the restoration.  In these situations, I typically remake the restoration with out charging and the problem is usually solved.

Forcing dentists to provide a five year warranty on crowns and bridges will only drive up the cost of care for all patients to cover the cost of replacement in patients with risk factors that cause higher failure rates.

Here are the links to the two paper I mentioned earlier.

http://www.ncbi.nlm.nih.gov/pubmed/18341238

Prediction of clinical outcomes of a restoration based on in vivo marginal quality evaluation.

I do not think there should be a five year warranty.  we cannot control a patients level of care that is the biggest determinant of how long dental work will last.

I applaud the comments previously stated from my fellow dentists and agree whole heartedly.  But another consideration is this: this rulemaking petition teeters on a very slippery slope.  I am gravely concerned about these types of provisions and the subsequent impacts that will follow.  As previously stated, there are too many factors to consider - many of which are completely beyond the dentist's control - when determining the longevity of any treatment; crown and bridge or otherwise.  Each patient is an individual with individual circumstances that may dictate the predictability and longevity of any treatment (a "crown" for one patient can be and many times is different than a "crown" on another).  Not to mention the patient's own treatment desires / choices when given multiple options.  I agree that there are existing provisions in place that patients can pursue should a treatment issue arise and that mandating some sort of warranty on treatment is completely unjustified.

I could not agree more with my fellow practitioners on the non-feasibility of mandating a "warranty" on crown and bridge prostheses.  My colleagues have more than adequately pointed out that there are simply too many extraneous factors beyond our control to consider this regulation as resonable. The comments by Dr. Fasano in particular were very pointed and factual and truly reflect the feelings of the vast majority, if not 100%,  of all general practitioners in The Commonwealth..

If there is some sort of defect in a restoration, it will become apparent in the first year, in which case I will happily remake the restoration.  There are too many patient related factors over which the dentist has no control to require some sort of across the board warranty. This should be left to the individuals involved, not to the government to decide. We have enough government interference already so lets leave what we can for reasonable people to decide.

As a consumer, it is not surprising to see that all dentists who responded  to date oppose the warranty. I am an 81 year old with some gold crowns that were installed 1n 1957-58 and still function well.  Fifty six years for a crown is pretty good. Of course those were delivered inthe days of $35 gold. I have numerous other crowns and implants. None have failed. My dental hygiene is  certainly less than optimal. I believe that my dentists are and have been highly skilled. I recognize that there is a lot of art in making crowns, bridges and implants.

The dental profession must also give consideration to extending a C&B warranty to implants.

We should RMrecognise that reasonable warranties must be subject to appropriate restrictions and limitations. I don't have the technical knowledge to draft these limitations, but my reaction is that a failure due to design, workmanship or material breakdown should be covered. A failure due to subsequent decay or related poor dental hygiene would not. 

As a consumer, I can not be concerned with related or remote third parties.If  an automobile part fails during the warranty period the consumer is not relegated to the supplier to the manufacturer. Presumably the dentist chose the lab and materials. An exception might provide for insurance company liability if the company refused to pay for a material that the dentist appropriately specified..

Some consideration should be given to making the warranty subject to the Virginia Consumer Priotection Act.

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The succes vs. failure of a medical procedure is governed by many factors, this also holds true for dental procedures.  The patient's biology plays a key role in the success or failure of dental procedure just as it does when a medical procedure is undertaken.   As with medical procedures there are rates of success and failure associated with dental procedures and therefore there can be no waranty associated any dental procedure.  Certainly if a patient believes he or she has been misdiagnosed, mistreated or malpracticed, he or she could and should pursue this.

When procedures are done by dentists there are a number of reasons why those procedures can fail but biology is is often a key factor effecting failure or success.  I understand a consumers frustration when any procedure results in failure, but he or she must understand that dentists are physicians of the oral cavity and the treatment of teeth and their supporting structures are comparable to medical treatment done elsewhere in the body.  There should be no warranty associated with any medical or dental procedure.  

     The Virginia Dental Association and its members abide by a strong Code of Ethics that was written to protect the public.  Our member dentists deliver crowns to their patients intending to have these restorations last much longer that 5 years.  Unfortunately, diet, poor dental hygiene, medications, and lack of saliva are some of the predisposing factors that lead not only to crown failures but other dental treatment as well.  To target crowns or any other dental procedures for warranty periods is simply ill founded.  The overwhelming majority of dentists take pride in their ability to privide quality dental care to their patients.  Adding additional regulations in the form of warranties would be burdensome to dental practitioners, impossible to monitor and completely unnecessary.

I too, like my colleges, am opposed to a 5 year C&B warranty.  If I'm to provide a warranty on the C&B work what warranty am I given by the patient that they will maintain good oral hygiene, keep a balanced diet, keep their dental recall appointments, stay away from prescriptions that cause dry mouth, monitor any bruxism habits, never have any trauma to the tooth, etc, etc. How about patients that live in nursing homes or retirement communites and have decreased manual dexterity?  What about patients that move? Also, what warranty are we getting from the lab that the crowns will last 5 years?  We don't make the crowns, and we can't control the patients habits.  

I myself have a crown, but if it fails in 5 years, I accept that the failure will likely have little to do with the dentist that seated the crown.  Also, if the dentist works for a community health center should the health center have to cover the cost of failed crowns?  Could this lead to a decreased rate of crown placement in patients that the dentists feel will not be able to maintain the oral hygiene or protective actions necessary to retain the crown? 

I echo and support the comments of my colleagues,especially Dr Norbo of the VDA and Dr Sarrett of VCU. As a dentist with over 20 years in private practice I have seen patients with restorations that have lasted a very short time and those that have lasted 50 years. What is the difference? Perhaps the quality of the materials and work but only in a very few cases.Overwhelmingly the difference between a restoration that succeeds and a restoration that fails is the patient. The patients' medical history,lifestyle,oral habits,health habits,committment to regular dental care, etc,etc,etc. All factors over which the dentist has no control. To force the dentist to  "warranty" such a situation is unreasonable , will place undue regulatory burden on practitoners and only cause the cost of care to rise for all patients.

In a perfect world, it would be great to be able to guarantee all of our dental work we provide. Unfortunately, it's unreal to expect all of our patients to be extremely diligent about not missing a recare appointment. We hear excuses all of the time for why people miss their regular cleanings. If that's the case, how is it fair to the dentist to guarantee work when some patients aren't prioritizing their own dental care. 

As dentists, we see so many patients who were once patients of another local dentist. How unfair is it to find decay around a crown which may be 4 years old and send that patient back to the previous dentist to have remade at no cost?  The other dentist has no clue how the hygiene has been maintained, etc. 

Dr.Chand, D.D.S.

I have been practicing for 19 years.  During seven of those years I worked as a subsitute, and saw many differnet styles of dentistry.  I have seen bridges last (patient reported) for thirty years.  I have seen (in my opinion) poor margins on some crown and bridge last for many years, because the patients took excellent care of  them.  I have also seen the opposite.  I have seen excellent margins (in my opinion) on some crown and bridge fail, because the patient did not take care of it as they should have.  They did not come in for regular dental hygiene appointments, as well as not regularly flossing, and what about using extra fluoride?  How can those gauges  be impliemented?  I myself had a crown with excellent  margins; I practice exellent hygiene, yet had a crown fail.  It happens.  Most dentists already offer a 5 year warranty on their work provided that patient practices regular preventive oral hygiene and has regular 6 month (or 3 month if periodontally involved) prophylaxis appointments.  I don't believe a blanket statement of  requiring dentists to give a five-year warranty on crowns and bridges to ensure work is durable and thorough, there are just too many variables that are beyond the scope of the dentists ablity to control.  

I agree with the previous comments of my colleagues that this is a BAD idea. It is unrealistic to require a warranty on a dental procedure with "human" factor involved( of variations of non-compliance) with oral care. Dr. Sarrett expressed some succinct comments with research to back it up. I do not support this idea and believe the comments will continue to follow this line of thinking.

To propose a warranty of 5 years or any amount of time for crowns and bridges is ludicrous. You simply cant paint with such a broad brush in matters relating to dentistry. There are countless factors involved in the success and failure of any restoration, both known and unknown; several studies in the scientific community confirm this.

Would you also have a surgeon warranty that a cancer will not come back after its removal for a specified amount of time? Anytime you are dealing with the human body and a persons individual genetic and behavioral makeup you can't reasonably expect to warranty anything. The human body is not a toaster oven.

Any dentist who does not take his or her craft seriously enough and do all he can to provide quality work that HE or SHE expects to last as long as humanly possible, will be weeded out by both the market place and/or the board of dentistry. Any dentist with a conscience would realize a manufacturing flaw that would lead to breakage, etc. and do the right thing. There is no need for a warranty as that will only create more red tape and more headaches for those who strive to do their best every day they practice dentistry.

Many factors out of a dentists control can determine the longevity of a dental restoration of any type.  These factors can change over time depending on a patients habits, health and activities. Informed consents for treatment should outline the concerns, limitations and pros & cons for any care to be  rendrered. All the factors known at the time should be understood and agreed. This is recognized practice and should eliminate misunderstandings on proposed treatment results.

I have no doubts that dentists would like the crowns they provide to last a iife time and  longer than 5 years. However, to make a legal  warranty requirement of dental treatments  provided would not be easily regulated or reasonable.

Respectfully submitted,

William J. Bennett,D.D.S.

While the idea of a 5 year guarantee looks like a nice concept- it is wrought with many flaws. The lifespan of a crown (or any dental restoration) depends on many factors, only some of which are under the dentists control. These factors include quality of laboratory work, quality of procedurural work done, condition of the tooth in question to start with, medical condition of the patient, home care performed by the patient, does the patient return regularly for check ups to monitor the restoration and quickyl and easily correct small problems before they cause a faiure, patient habits (such as never brushing or bruxism) and so on. I will illustartate several situations where a crown may fail due to no fault of the dentist or the laboratory.

1. Trauma- accidental fracture of the restoration or the underlying tooth due to excessive forces of trauma

2. Bruxism- what if a patient refuses a gold crown for a second molar (recommeded because it can't break) and chooses a porcelain crown that later breaks because of undue stress from bruxism

3. Root canal therapy- some crowns need root canals after they are completed. A hole must be drilled through the crown to do the root canal- this can weaken the porcelain and cuase it to frature

4. Poor home care and recurrent caries under the crown margin can cause a crown to fail

5. The patient insists on trying to save a tooth that is nearly hopeless, so the dentsist does his best, in fact does it perfectly- and it fails after a few years- the patient was informed and knew the crown would likely not last 5 years to start with- and is happy with 2 or 3 years

These are a few situations where, for reasons beyond the control of the dentist, a crown may fail. Some of these are a result of poor decisions on the part of the patient after being informed of options available. In each case, to force a dentist to replace a failed crown would be inappropriate.

Most dentists just do the right thing anyway. If my patient were to have  a crown fail within 5 years, we would have a discussion as to why. If I felt there was any fault of mine involved, I would offer a resonable solution- like replace for free or maybe charge a new lab fee. This is the free market and those who don't stand behind their work will weed themselves out of the mix. You cannot legislate ethical and good behavior- but you can punish the masses for poor behavior of the few. Dentists, for the most part, will do the right thing.

Do not go down this path, it will only lead to confusion, higher costs, and patients not getting what they want. None of these are in the best interests of protecting the public.

The vast majority of crowns and bridges endure at least five years and many laboratories provide such a guarantee. Many insurance companies will only reimburse dentists for a new crown  5 years after a crown was placed on a given tooth. However, the laboratory crown guarantee requires that a patient show proof of regular dental visits every 6 months. Even with regular dental cleanings and check-ups every 6 months, a  dentist cannot guarantee that tooth decay, periodontal disease or a fracture will not occur to destroy the tooth itself which then causes the crown or bridge to fail. Today's dental patients include many who are taking  one of the more than 500 medications known to decrease the flow of saliva which in turn increases the rate of tooth decay. After age 50, the mineral composition of teeth changes and makes  teeth more prone to fracture. Periodontal disease can also cause a major periodontal defect within a short period of time which then condemns the tooth to extraction. It is therefore not possible to guarantee anything for any period of time in dentistry. Durability of dental treatment varies with the condition of the tooth when treatment is rendered and  with the dietary  and oral hygiene habits of the patient. Requiring a 5 year guarantee for all crowns and bridges will foster the unnecessary extraction of slightly questionable teeth and their replacement with implants. This will  increase the cost of dentistry to the patient and to society.

It is unreasonable for dentists to have a five year warranty on full coverage crowns. Many factors determine the success of a crown as many people have already listed on this forum.  It was commented earlier on this forum that the number one reason why crowns fail is due to decay around crown margins.  Decay is a multifactorial issue and certain patients are at higher risk for decay than other patients.  This pattern of decay should be discussed during the informed consent of having a full coverage restoration placed.  If the patient is informed that they are at higher risk then the situation is analagous to placing a warranty on automotive brake pads for the driver that has his/her foot on the gas and brake pedal at the same time while driving down the highway.     

It is unreasonable for dentists to have a five year warranty on full coverage crowns. Many factors determine the success of a crown as many people have already listed on this forum.  It was commented earlier on this forum that the number one reason why crowns fail is due to decay around crown margins.  Decay is a multifactorial issue and certain patients are at higher risk for decay than other patients.  This pattern of decay should be discussed during the informed consent of having a full coverage restoration placed.  If the patient is informed that they are at higher risk then the situation is analagous to placing a warranty on automotive brake pads for the driver that has his/her foot on the gas and brake pedal at the same time while driving down the highway.     

The Virginia Board of Dentistry is made up primary of dentists; therefore, I trust you will deem this request unreasonable. The request for a 5 year warranty on crowns is unreasonable. As an orthodontist, if relapse occurs shortly after retainers are inserted and the patient has been cooperative, I will often retreat for a short duration at no charge. When former patients come back for a touch up, I may give a small discount as a thank you for their loyalty. However, I make no guarantees and certainly not for the entire fee. These courtesy discounts are at my discretion. I do not participate with any insurance that caps fees at discounted rates. However, if I did, I imagine it would be significantly more difficult to extend these courtesies. A crown has many variables for its initial success and longevity. What this petition is asking for is not doable for the vast majority of practices.  

I believe that a warranty on crowns should be up to each individual Dentist.  A mandate from the Government is an intrusion on the patient/doctor relationship. There are too many variables that accompany a warranty on a crown. Currently, most labs guarantee the product (i.e. porcelain and metal) for 5 years as long as the patient is seen every 6 months for an oral exam and prophy. To guarantee total coverage of a crown is ridiculous. The reason most Dentist oppose this petition is for the following reasons:  The best fitting crown can fail in 2-3 years with improper oral hygiene. Plus, I have seen a marginal crown survive 15+ years with excellent oral hygiene. A problem with a guarantee is once you give a guarantee, what happens when the patient does not show up for recall appointments? Why should a Dentist be responsible for a patient's neglect? What happens when a patient refuses radiographs?  I can tell you that I have seen this in my own practice.

Due to the problems that we as Dentist face, I strongly oppose this request!!

Crowns, bridges, partial dentures and dentures, etc. are services, not consumer products. Having to warranty not only the crown but all of the associated costs would greatly increase fees to patients.

Also, for those patients with low insurance  fee schedules and especially Medicaid patients, access to care would be severely restricted.

The regulations to address all of the possible scenarios involved with crown failures would be hundreds of pages long and in the end will still end up being an ethical decision as to the reason for a failure.

I personally use a lab that guarantees their crowns and bridges for five years against porcelain fracture, etc. providing the patient has been on a regular recall schedule. I have no problem with making crowns over when the problem was not caused by neglect or abuse.

It would be interesting to see how the orthopedic surgeons would feel about an all-inclusive warranty on hip and knee replacement.

Dental prostheses, including fixed crowns and fixed partial dentures, are fabricated to become a functional part of a patient's anatomy.  Although the dentist and patient should have assurance regarding the composition of the prosthetic, which I believe already exists in the VA statutes, assurance regarding the patient's functional anatomy is complicated and dependent upon many factors.  Although well meaning, this proposal is impractical given the multitude of variables that contribute to human anatomy and physiology. Respectfully submitted by Guy Levy.

I strongly oppose having a mandatory warranty on any dental prosthesis like crowns, as there’s many variables involved in its success ,longevity and/ or failure, including biological and biomechanical factors. Warranty and courtesy discounts should be left at the dentist's own judgment and personal discretion and based on case by case evaluation.

Our company deals directly with this issue on a daily basis.  In my opinion, the dentist should not shoulder the full burden for things outside their control as many have stated here. 

I do believe, however, that the patient's basic desire behind this rule change request is for better communication and peace-of-mind when faced with the cost of a crown or bridge.  Perhaps they had a bad experience with a failed treatment? 

At any rate, if patients are demanding a higher level of assurance against life events (which are outside of the dentist's control), an alternative to a state mandated warranty is a third-party warranty or protection plan.  For example, our 5 yr protection plan covers the cost of all of the items listed by Dr. Hutchinson above, including trauma or accidents, bruxism, root canal therapy after a crown has been placed, recurrent decay, and others, and also gives the patient nationwide protection if they move. In this way, the dentist doesn't have to take on the added risk and cost of a mandated 5 year warranty, but the patient still has the extra assurance available.

I don't say this to promote our product, but just to point out that there are other ways of solving the issue then adding a regulation. 

The problem is this. Every patient and tooth is different. Some people grind their teeth, some people don't brush their teeth, some people don't floss, some people chew ice, some people have a high caries rate due to medical conditions, etc. The long term prognosis for any dental work is different from tooth to tooth. It's like doing a knee replacement on someone who is in perfect health and exercises regularly and doing the same knee replacement on an obese person with uncontrolled diabetes. Two completely different cases with different probabilities of success.  The key is patient education and expectations. They need to make informed decisions. Dentists must be beneficent and make case to case determinations on warranties considering all factors. This is in regards to all treatment...not just crowns.

Holding the dentist to a 5-year warranty on crown/bridge is simply wrong. There are numerous variables beyond the dentist's control that cause clinically sound crown/bridge to fail on or before 5 years such as poor oral hygiene, failure to show up for recare appointments, and occlusion issues (a patient with no posterior occlusion needs a crown on an anterior tooth, but cannot afford or is not willing to restore posterior occlusion). A home builder is only required to warranty a new home for 2 years in our state, but there is a call for dentists to warranty crown/bridge for 5-years. There needs to be dual accountability in the dentist-patient relationship, and the responsibility should not only be placed on the dentist.

The problem with attempting to place a warranty on major dental work is that we as dentists don't work in a static environment.  Many factors can change the oral condition, some even beyond the patient's control much less the dentist's .Systemic diseases, medications as well as a patient's physical and mental limitations can all produce an oral environment more conducive to decay.  And the patient's responsiblity can not be negated.  Keeping up with regular dental visits to maintain proper care is as important if not more so than the skill of the dentist. 

I would oppose this proposed regulation based on clinical research findings on reasons for failure of dental crowns and bridgework. These findings place the most common reasons for failure on patient compliance. Recurrence of decay around these appliances is the major cause of failure and this is caused most often by lack of good hygiene & regular dental care,  the individual's oral environment and the general health of the patient.  Mechanical failure of the actual appliance is rare. It is very difficult to make a guarantee of patient compliance.  

I can't really add much that has not already been said by my colleagues in this Town Hall Forum.  I do see this as a poorly concieved concept that is universally rejected by people who understand dentisty.  Therefore, why is it even being reviewed by the Board?  Why would a citizen propose such a petition if not guided to do so, and why wouldn't the board reject it as ludicrous before putting it into the Forum format?  

Is the Board required to put every proposition into this format, regardless of appropriateness?  Some  editorial comment seems in order.  Why does the dental association have to keep on the lookout for ridiculous things like this, so that absurd propositions do not actually develop into lawful requirements?  If we can't get the Board to address illegal dentistry issues like tooth bleaching in the mall, or dental "grills" made by jewelers, how do things like this petition get any support to be reviewed?

The Board automatically takes every complaint and turns it into a case for inspection, regardless of validity.  They do not tell the complainee that no financial settlement through the Board is possible.  The Board also does not tell complainees about the Peer Review Committee of the Virginia Dental Association, which has an amazing success record at satisfying complaints financially and promptly.  If anyone wants to make a meaningful petition for the Board, change how the Board answers the phone, and how cases should not be automatically generated.

I must agree with Dr. Roggee;

crown warranty

I can't really add much that has not already been said by my colleagues in this Town Hall Forum. I do see this as a poorly concieved concept that is universally rejected by people who understand dentisty. Therefore, why is it even being reviewed by the Board? Why would a citizen propose such a petition if not guided to do so, and why wouldn't the board reject it as ludicrous before putting it into the Forum format?

Is the Board required to put every proposition into this format, regardless of appropriateness? Some editorial comment seems in order. Why does the dental association have to keep on the lookout for ridiculous things like this, so that absurd propositions do not actually develop into lawful requirements? If we can't get the Board to address illegal dentistry issues like tooth bleaching in the mall, or dental "grills" made by jewelers, how do things like this petition get any support to be reviewed?

This proposal assumes that crowns are commodities like televisions, automobiles or computers. We all know that the success of any medical treatment involves the participation of the patient in this process. As medical professionals, it is our responsibility to educate patients and guide them in showing how their actions can contribute to the success of our treatment. Furthermore, it is our responsibility to provide patients with treatment that follows standard of care. It is also the patient's responsibility to properly follow our instructions in maintaining his/her oral health. 

We should have flexibility in dealing with unsuccessful treatment. There are already regulations in place that address failures due to not following standard of care. We should not be burdened by additional inflexible regulations. Should cardiac surgeons warranty bypass surgeries (what if a patient continues to smoke...)? Should plastic surgeons warranty facelifts (what if a patient continues to sunbathe everyday...)?

In conclusion, do not treat crowns as consumer commodities. Thank you.

In placing a fixed prosthetic restoration we are dealing with human tissue, human psychology, human behavior, and human host responce, all of which are variable in mostly out of the dentist's control. These factors plus others not mentioned influence the clinical life of a prothesis.

If health care ever gets to the point of warranting how long a patient wil live then maybe a 5 year warranty on dental prosthetics may be in line!

A 5 year warranty is an absurd notion.

Can you imagine the litigation and regulation that might result!

It's all been entered by my colleagues already.  I can place the best crown or restoration in the world but if the patient does not do their part at home my work is often in vain. 

A warranty on crown/bridge is not going to work in my opinion.  There are many factors which result in the success and/or failure of a crown.  I would say a majority of the cases I do are successful, but there are those cases which patients are non-compliant and don't follow through with regular dental care and follow up.  There can be lab errors.   What if there was material ie impression used that we later found out to be defective.  Do we then go back to the manufacturer and ask them to pay for the patients new crown?  How do we monitor what patients do outside of the office ie foods, drinks, habits, oral hygiene; medical factors, medications, etc.  Why should I the dentist be penalized for something that is out of my control?  I believe if there is a crown that is made, and it is due to an error on the dentist part, then the dentist shouldl remake the crown at no charge to the patient.  I strongley believe that it should be left to each dentist to determine the circumstances and try to work something out with the patient on a case by case basis.  If you start putting a warranty on crown/bridges then soon after there will be a warranty on all dental procedures.  How can you put a warranty on healthcare as it is not a product?  I believe most dentist out there try to do their best to serve their patients.  I find that insurance sets up these parameters ie 5 years which then set the standard of care when actually the insurance sets these limits based on their profitability not what is in best interest for the patient.  I request that you do not put a mandatory warranty on crown/bridge.  Thank you for reviewing my opionion.

Dr. Vandana Sood

Not to repeat what others have stated about the inability to warranty restorations, but the original tooth failed at some point due to neglect, diet, etc. Was there a warranty with the tooth to begin with?

We already offer a similar warranty.  However, there are two issues that need to be addressed, since this only works if there is bilateral responsibility.

Patients must maintain a reasonable oral hygiene and examination protocol.

Trauma and accidents are not covered under the warrantee.

You can't have patients disappear for 5 years and then claim that your dental work failed, for whatever reason.  I've dealt with these over the years, and have had no problems with patients who I have been seeing on a reguiar basis, but have had problems with patients whose dental condition is degrading unsupervised, or have never returned for any followups, or what appears to be a trauma situation, etc.

Another option is to have a sliding scale of  "responsibility".  The expectation would be different at three months as opposed to 59 months after initial completion.  Most true failures will occur sooner rather than later.  Later failures tend to be neglect or trauma related.

Failure must also be defined.  Does failure of the underlying tooth structure consitute failure of the restoration?  Would a slight porcelain chip which doesn't compromise longevity or affect esthetics , and could be smoothed out, consitute failure of the restoration?  What about recession?   These types of issues must be dealt with beforehand.  It gets more involved in the regulatory areana if dealt with after the fact.

I’m concerned that the requirement to warranty dental care will harm the public due to the influences dental warranties will have upon treatment presentation and decision making.       

Dentistry is both a profession and a business that we all rely upon to support our families and provide a moderate standard of living.   Although a crown may be the ideal standard of care, why would I recommend a crown if I have to warranty it?   I may “patch” a filling, that although meets a minimal standard, is a far inferior long term treatment choice.  Will I recommend an extraction rather that a crown, knowing that a four Mountain Dew a day habit will destroy any care I provide and therefore be forced to extend a warranty?   We face daily less than ideal treat plan situations and discuss openly with our patients the benefits and risks of care when we have less than an ideal prognosis.   These discussions lead patients to make decisions of informed consent.   Will I continue to do this if it is going to cost me money to replace a crown?  Teeth ravaged by decay and the need for endodontics, symptomatic cracked teeth, periodontally involved teeth.   Why not just recommend extraction to protect me and my business profit margin?  I can’t control what a patient does when they leave my office.

We as a profession are ethical and morally bound to provide a standard of care based upon mutually agreed upon treatment plans and iformed consent .  Leave us alone to do it.      

I’m concerned that the requirement to warranty dental care will harm the public due to the influences dental warranties will have upon treatment decision making.       

Dentistry is both a profession and a business that we all rely upon to support our families and provide a moderate standard of living.   Although a crown may be the ideal standard of care, why would I recommend a crown if I have to warranty it?   I may “patch” a filling, that although meets a minimal standard, is a far inferior long term treatment choice.   Will I recommend an extraction rather that a crown, knowing that a four Mountain Dew a day habit will destroy any care I provide and therefore be forced to extend a warranty?   We face almost daily less than ideal treat plan situations and discuss openly with our patients the benefits and risks of care when we have less than an ideal prognosis.   These discussions lead patients to make decisions of informed consent.   Will I continue to do this if it is going to cost me money to replace a crown?  Teeth ravaged by decay and the need for endodontics, symptomatic cracked teeth, periodontally involved teeth.    Why not just recommend extraction to protect me and my business profit margin?  I can’t control what a patient does when they leave my office.

We as a profession are ethical and morally bound to provide a standard of care based upon mutually agreed upon treatment plans.  Leave us alone to do it.      

   I do not believe placing a warrantee on dental work is a good idea.  The life expectancy of dental work is dependent on many factors, including a patients personal oral care, diet, alcohol consumption, smoking, hereditary and environmental factors, maintaining regular dental checkups, occlusal habits, to name a few.  Foods effect pH of the mouth, the potential for decay and the longevity of dental work.  Coffee, even without sugar, sodas with sugar and sugar-free, power drinks, all are very detremental to natural teeth and dental work.  A patient's lack of home dental care also effects the health of the teeth, dental work and periodontal health.  

   The location of a restoration can also be a factor in its longevity.  Patients who grind their teeth weaken and destroy fillings at a faster rate than those who do not.  Deeper restorations can have more potential for weakening teeth.  Teeth that have decay but are assymptomatic can become symptomatic when treated.  The number of restorations in the mouth, the presence of missing teeth, the presence of removable dentures all effect dental work longevity.

    In addition, treatments that are recommended by the dentist to preserve dental work and teeth are often not accepted by the patient, or are not done because the treatments are not covered by insurance companies.  At present, many dental treatments that are in the best interest of the patient are refused by insurance companies as unncecessary.  Were these treatments to be done, the overall health of the dentition and existing restorations would be improved.

   There are far too many factors associated with how well dental work will hold up in the oral environment to accurately ascertain the 'life expectancy' of dental work.  Trying to regulate such would only serve to create unrealisrtic expectations and reduced personal responsibility on the part of the patient.

I personally believe that no two patients are alike. Some follow their dentist recommendations,others don't. Therefore even though an office may have certain policies regarding re makes, but those should be general guidelines. I have seen crowns placed 40 years ago and still good, others didn't last evens year. There are many factors that affect the long term longevity of crown such as caries risk, perio, poor hygiene.. etc

Therefore I don't think a 5 year warranty should be mandated.

I can only applaud the numerous comments already posted here that show the flawed logic behind this petition.  As others have pointed out repeatedly there are many extraneous factors over which we have no control regarding treatment outcomes.  We are providing a service, not a commodity when we do anything for our patients.  Does any resonable person expect  such blanket guaranties from their physicians when the have hips, knees or heart valves replaced?  Of course not.

The remarks of Dr. Hutchison are particularly germaine.  The vast majority of dentists are ethical and will do the right thing by their patients, regardless of whether such a misguided regulation is in place or not.      

Yes, there cases where crowns and bridges have lasted many years. However, there are too many outside factors that influence the longevity. Is the patient complient with his home care? Does he see his dentist on a routine basis? If their diet is high in acidic foods or beverages the incidence of deay is greater. What if they are a bruxer or ice chewer the porcelain can fracture.There are just too many things that are beyond the dentist's control to guarantee his work if the patent is not doing their part.

Therfore, I am against such an action by the Board.

To whom it may concern ,

Certainly dentistry has a lot of technical work involved in it but I and all the dentists including the specialists will tell you that dentistry is a health care profession ! In life when God himself has not guaranteed our life and our parents who created us have not given any warranty on our lives , how do you expect us to give any kind of warranty on anything !! We all are trying our best to provide the best quality of care to everyone and not just patients who need crowns and bridges !! I feel that we are being persecuted for being in this profession !! If this warranty is to take affect then we will all have to stop practicing and providing the best for our patients . I think the board should realize that this kind of petition should not even be discussed since the board was made for us dentists and should support us in this endeavor and prevent  this kind of issue to even crop up . I hope and pray that the board accepts our  sincere request to void this petition and doesnot allow these kind of petitions to ever come up again . 

Thank you so much ,

Sincerely,

K.Hyder