top of page
  • Dr. David Alfaro

I clean teeth.

So I am going to rant here......

I recently joined a dental specialist forum on Facebook. It is a group that shares articles and discusses topics surrounding our lives and careers as dental specialists. One of the roles of this group is to connect people as well.

A doctor posted to the group a recent request for a recommendation for a prosthodontist in their area because they had a patient with severe tooth decay that was challenging to manage. One of the first replies was, "I love prosthodontists, need to manage the caries......and if that doesn't work refer them to the prosthodontist for implants."

This was shocking to me.

Prosthodontics is an obscure dental specialty; there are only 37 of us registered in BC and a half dozen of those are near retirement or working solely in academic or hospital settings. Dental students are not picking it as a specialization. Out of my graduating class at Columbia, where we had a dozen people go into orthodontics, a dozen into OMFS, and another dozen into pediatric dentistry, we only had 3 enter prosthodontic programs right away, and one more student a year later. My accountant has even told me that I am in a dying specialty!

Not many people know what a prosthodontist is, or what we do.

But I figured of all people to know the role of the prosthodontist, it would be another dental specialist. How could this person assume that a prosthodontist would not be able to manage the patient's caries?

Let us talk disease management.

I clean teeth.



Not my hygienist. I do not refer to a periodontist for cleanings..... who by the way would likely not be doing the cleanings themselves.

I sit down and scale and debride the teeth of every single patient that is in my office for routine dental care. And if someone is directed to my office from another clinic and there is plaque or calculus present on his or her teeth, the first thing I do is chat with the referring doctor and let he or she know that the patient is due for a hygiene appointment, and that if they want, I can take care of it myself. Me. Not a hygienist.

So this is why I am so angry that another specialist would assume that a prosthodontist would not be the right choice to help manage that patient's dental caries.

Why do I clean teeth?

People do not often end up in a prosthodontist's office because they have healthy clean mouths. They have tooth decay. They have gum disease. The have dead or dying teeth. They have broken dental work. The do not know how to manage their oral health properly; things are a mess.

These are not static processes; they are a continuum of disease that need to be managed chronically. The first step in any prosthodontic care is therefore disease management.

So that is what I do.

I speak to every patient myself and ask them what their goals are, and what their habits are. Yes, I have forms that they fill out, but really, those are just legal requirements to me. I sit down and find out where someone is in their oral health patterns personally, in an interview, and then during a comprehensive exam.

Then I clean their teeth.

To me, providing someone with a dental cleaning is much more than just cleaning their teeth. I get to really complete the examination at this point. I get to know exactly how well each and every one of their fillings or crowns are fitting, I get to find out where they have problems cleaning, and I often catch periodontal pockets and dental caries that were not so visible in my first examination. I also get the chance to determine if the person requires more aggressive behavioural and/or chemotherapeutic interventions to get them on the path to good health.

A cleaning is much more than a cleaning.

Furthermore, it is the first step in the management of both periodontal disease and dental caries. Why would I pass this job on to someone else? Because my practice is too busy? Because I have been trained to provide very complex dental work? Because it is below my training level or pay grade?

The reality is that it is not often cost effective for dentists to be performing extensive examinations and dental hygiene appointments at most offices, especially in Vancouver. We have crazy lease payments. We have massive staffing costs. We have hundreds and thousands of dollars of student loans to pay off. Fancy offices are the trend, and that equipment costs money. It would not be unreasonable for a practice to have hundreds if not thousands of dollars of overhead zipping by per hour.

A dentist working in that environment would lose money if they sat down with someone for an hour to clean their teeth. It is simple economics.

So I have insulated myself from that.

I have one receptionist, and one assistant. That's it. I have a small office in the suburbs. I do not have a view of downtown, nor do I have unnecessary gadgets in the office. I dont own a car and I take the train to work.

But I am lucky that as a specialist, I spend most of my time performing complex dental care. This allows me to sit down with each and every one of my patients and give them the time that that is required in order to make positive changes in their oral health, be it a simple cleaning, or dental implants.

Yes, performing hygiene myself is not the most lucrative way for me to manage my practice, but it allows me to be efficient with my time while keeping staffing to a minimum. I see a couple of patients a day for complex prosthodontic care, and then am freed up to take care of my maintenance patients while my assistant sets up for the next surgery or cleans up for the day. I don't run around and every one gets my full attention. I don't need a second assistant and I do not need to be seeing multiple patients at a time. Although I could be.....

I do sometimes wish that I had that fancy office with a gorgeous view and marble floors, or a $100K vehicle, but that is not me. I would not be able to sit down to chat with someone for an hour while I scale away plaque and calculus. And to me this is important. I have enough complex dental work to keep me busy and stressed out, and I have this work because people are not taking care of themselves. If I am not sitting down and helping them improve their health patterns, I am not being the best prosthodontist that I can be.

So I hope that the gentleman who wrote that comment takes a moment to read this article and realizes that as a prosthodontist, the first thing I do is manage disease. Before any fancy aesthetic porcelain veneers, or dental implants or removable dentures. And if I succeed at managing disease, maybe my patients will need less of my speciality care, and if they do, hopefully it will be later on in life.

One of the goals of my blog is to educate the public (and other dentists too, I guess) about speciality dentistry, and prosthodontics in particular. People do not know what we do, but little by little, I want people start recognizing that we should not be a last resort for people with failing dentitions, but are integral part of the spectrum of general dentistry referral services, and that patients should not be afraid to seek out care at our offices on their own.

Doesn't your smile deserve a specialist's attention?

Thanks for reading!

Dr. Dave

Featured Posts
Recent Posts
By Category
Search By Tags
bottom of page