I still needed a supportive abutment and the tooth-shaped crown, which would fit on top of the implant in the space where the natural tooth used to be.
My regular dentist said she could do it. Great, I thought. Then she quoted a fee.
It was a staggering $3,000, meaning my total cost would be almost $5,000 to replace a single tooth. I was nearly speechless.
To be sure, living in Bethesda can be expensive. So I called a dentist I knew in Cumberland, Md., Her price was $2,000 — a third less, but still too high for my budget.
My Bethesda dentist was sympathetic but said she couldn’t negotiate. The crown is custom-made by a lab, and it isn’t cheap.
Here’s what’s involved: After the implant bonds to the jawbone, which takes about six months, the dentist attaches it to the abutment, a small connector post designed to support the crown. The dentist takes impressions of the teeth, creates a model of the bite, and bases the crown on this model. The lab makes the crown, and the dentist attaches it to the abutment. The end result looks just like a real tooth.
I hadn’t gone this far to stop in the middle. But how to pay for it? My dentist had an idea: “Why not have it done at a dental college? Dental students learn by practicing on patients, and it’s all supervised by professionals. And the school will charge you a lot less.’’
It was a great piece of advice.
Shortly thereafter, I became a patient in the prosthodontic clinic at the University of Maryland School of Dentistry in Baltimore.
It took a considerable amount of time, but it was worth it. I received excellent care, and a beautiful new tooth.
I also saved a bundle of money.
A genetic legacy
People lose teeth for many reasons, including disease and injury. My genetic legacy was the gum disease and bone loss that had afflicted my mother. She lived to 100 but died toothless. One of my enduring childhood memories is the vision of her dentures soaking in a glass beside her bed.
To be sure, many advances available today didn’t exist when she was growing up. Moreover, her generation knew little of home care beyond brushing. (Flossing still was in the future even when I was a child.) Her teeth were pretty much gone by middle age.
Hoping to avoid her fate, I took scrupulous care of my teeth and have managed to hold on to most of them. Nevertheless, I began to lose bone. With no supportive bone, teeth begin to loosen, infections develop and extractions inevitably follow. I had several surgical bone grafts, with mixed success. I lost five teeth, but because they were located at the back of my mouth, they could not be seen and caused me almost no trouble.
What convinced me to try an implant was the loss of the first molar on the lower right (in dentalspeak, No. 30), which threatened the healthy tooth directly above it. Without a tooth to bang down on when chewing, the good tooth would have started to drift, eventually messing up my bite. A less expensive bridge was not an option, because the adjacent molar also was among the missing.
If implants make it through the first year — 95 percent of them do — they are likely to last a lifetime, says Carl F. Driscoll, president of the American Board of Prosthodontics. Unlike natural teeth, they aren’t vulnerable to decay, though they could suffer surrounding bone loss.
Insurance plans generally don’t cover implants because many insurers still consider them experimental “even though they’ve been around for 35 years,’’ Driscoll says.
If I wanted to finish this implant, I was going to have to pay for it myself.
A different model
It’s not unusual for patients to be treated by medical students who are working under supervision; this approach is, in fact, integral to the nation’s more than 1,000 major teaching hospitals and health systems.
With several major medical schools in the area, most of us who enter a hospital will interact with an intern or resident — a medical school graduate, but still a doctor in training — and won’t find it surprising. Also, medical students routinely rotate in and out of doctors’ offices. Receiving care from these students is usually no cheaper for patients, according to the Association of American Medical Colleges.
The dental school model is different. The University of Maryland School of Dentistry, which accepts insurance, offers clinical services at reduced prices, often as much as 50 percent less than the private sector. The dental students “are here to learn how to do it right,’’ says Driscoll, who also directs the college’s advanced prosthodontics education program. “Making money is not the bottom line.’’
Maryland’s isn’t the only dental college in the Washington area. Howard University College of Dentistry also offers patient services at significant cost savings. “Many people come to us for simple and complex procedures that would cost them much more if done by private practitioners,’’ says Leo Rouse, dean of Howard’s dentistry school and president of the American Dental Education Association.
Established in 1840 as the Baltimore College of Dental Surgery, Maryland’s was the world’s first dental college. Today it offers patients a general dentistry clinic and care in five specialties: prosthodontics, periodontics, endodontics, orthodontics and pediatrics.
Prosthodontists restore and replace teeth. Maryland’s three-year prosthodontic residency program includes training in dental implants, tooth preparation, crown fabrication, casting, investing and porcelain application, dentures and removable partial dentures. Part of the learning process is providing treatment to patients, with cases becoming more complex as the student’s experience grows.
I made six visits to Baltimore over five months. All but the first appointment, a general screening, took about three hours apiece. By comparison, my Bethesda dentist, already aware of my dental history, would have needed only two visits, of 60 and 45 minutes.
Time-consuming, yes, but remember: I was not only a patient but also a teaching tool. This meant, among other things, that students frequently photographed the inside of my mouth for exhibit during resident seminars. Also, supervisors checked each step along the way. I never felt impatient; rather, I found this reassuring.
“We go into depth, not just the hows, but the whys,’’ Driscoll says. “One of the nice things about the residency is that everyone knows everything about everyone’s patients, except their identities. You were ‘Ms. C.’ when presented.’’
I went specifically to finish the implant, but the process included a full-mouth evaluation. I learned that I have significant bone loss (no surprise), some loss of connective tissue (a surprise), that I am a night-grinder (night guard recommended) and that the crown on another tooth — No. 29 — was broken. Did I want that one replaced? Since my insurance covers regular crowns, I told them to go ahead.
The first-year resident assigned to me, Ying Han Tan, was an affable young man who had graduated from the National University of Singapore’s dental school. Being relatively new at the time, he got me because my case was simple. He seemed both bright and competent — and endlessly preoccupied with my comfort. “Are you in any pain?’’ he asked, repeatedly. I wasn’t, ever.
During the subsequent appointments, Tan took additional X-rays, made impressions of my teeth, removed the broken crown and fashioned a temporary crown for No. 29, and took considerable time matching the new porcelain to the color of my natural teeth. Residents do almost all of their own lab work. Thus, Tan would be making my two crowns himself.
There was only one unanticipated delay. I arrived for my fifth visit on Feb. 22, expecting it to be my last. Tan installed both new crowns in my mouth, and we waited for his supervisor to inspect them. She pressed a device of silicone material called a “fit checker’’ into my mouth to ensure that both crowns fit properly. One of them, for tooth No. 29, wasn’t quite right. She told Tan to do it over.
I was disappointed, of course, yet this development boosted my confidence in the clinic. “Where else can you go where all the work is checked by someone else?’’ Driscoll says. “Certainly not in the private sector.’’
I returned March 8, and this time the fit was perfect.
My cost to finish the implant: $1,416. For sure, I spent in time what I saved in money. But the trade-off was well worth it.
Cimons is a former Los Angeles Times Washington reporter who lives and writes in Bethesda.
Prospective patients seeking information from the University of Maryland School of Dentistry should call 410-706-7101. For the Howard University College of Dentistry, call 202-806-0007 or 202-806-0008.