(continued) “Tiers” within the dental profession:

And so, it has come to a point where a dental practice is defined based upon how it chooses to deal with these realities. Let me offer you these definitions. We now see the development of three definite modes, or “tiers” within the dental profession, which exist based upon the viewpoint of the dentist and his/her basic values

Tier 1 – This is the dentist who is basically “putting out fires,” seeing patients who just want to get out of pain through having teeth removed, or basic “patch and repair.” These dental practices are heavily based upon insurance company policy, and the patient may be treated by several dentists who have little time for interaction or teaching. I would say that I practiced this type of dentistry in the earliest stages of my career after I graduated from dental school

Tier 2 – This type of dentist is also very common. This is the dentist who primarily is a “fixer,” perhaps even touting “cosmetic dentistry” to attract new patients. They may educate the value of having good dental repair, having teeth cleanings regularly, and a “perfect smile,” but don’t take it much further, as they are also influenced by insurance company policy that has more to do with its bottom line than the health of its enrollees (patients). I confess that I passed through this mode of dentistry as well. Within this mode I discovered that there was little time to teach and provide high quality services, as the insurance companies were in essence dictating how much time I should spend with my patients. I eventually had to get out of that mode, as I felt that the regulation of my dental practice based on insurance company policy was a disservice to my patients and conflicted with my sense of ethics.

Tier 3 – This is the dentist who practices “Health-Centered Dentistry,” to which I aspire. It views dentistry from wellness and learning rather than just treating the results of disease. I made a decision in the years after dental school to search for more educational experiences that looked at the “bigger picture” of the connection between dental health and general health. During this learning evolution, it became more and more apparent that each patient is unique, with individual needs. A health-centered approach was what naturally followed this ongoing learning process. I now take the time with each patient to delve further into diagnosing their dental needs, and thus provide a wider range of preventive and treatment services. This interactive process is very important because it facilitates the development of trust. As indicated, trust is of paramount importance in the healing professions, especially dentistry. Many patients who have described past negative dental experiences to me say that the dentist spent little or no time with them from the beginning, which resulted in rushed diagnosis and uncomfortable and/or poor treatment. Trust was not given a chance to develop, so the patient eventually learned to avoid going to the dentist altogether, until their pain finally outweighed their fear. This negative experience is completely avoidable, and I have learned that the uniqueness of each person demands that they cannot just be put into “time slots” to fill appointment times on my schedule. Excellent dental service can only occur where quality becomes the constant, and time the variable, not the other way around.

I have noticed that only a few of the dentists out there have “taken the leap” and moved on to the Tier 3, health-centered mode. This is probably due to a combination of the above-mentioned factors. The tough question for me was, “How can I exist and be nurtured through really helping people if they only relate dental fees to things being “fixed?” Will they pay for relationship building time, data collection and diagnostic procedures not covered by dental insurance?” It was difficult and risky for me to all of a sudden change my office, staff and systems into a Tier 3 practice, so I tried to ease into a Tier 3 mode while still practicing Tier 2. The question then became, “How would I manage in one facility, two distinctly different modes of dentistry?” I discovered the futility in attempting to “serve two masters” by providing both Tier 2 and Tier 3 care under the same roof. I tried for some time to “dance to two tunes,” but discovered that it didn’t work. I have seen other dentists try this and fail. I still don’t know of any dental practice in which these two tiers co-exist successfully. I have discovered that if I wanted my patients to benefit as I have through the knowledge I have gained, I must cherish, and therefore allot the time necessary for my patients to realize these benefits. I must “assume the full mantle” of Tier 3, so to speak, rather than tiptoeing back and forth between the two, no matter what the risks.


The challenges…

I have found dentistry to be a wonderful and challenging profession, one that is a true blend of art, science and skill. As crucial as it is to provide excellent technical skill, the one type of skill-learning that was missing in dental school was that of interpersonal relations. Which leads me to my next point that was another important realization: No matter how gifted, skilled or technically able the dentist may be, true dental health cannot be achieved by the dentist alone. It must involve the participation and partnership of the patient as well. This is why I take the time to get to know my patients, and to gain their confidence and trust before we even begin dental treatment. If one has a willingness to learn and improve as a patient, combined with my expertise and passion as a dentist, the true formula for success appears! This relationship development and emphasis on patient learning is the core of what has been called the “health-centered” dental practice, to which mine has evolved.

A little insight into the dental profession: Most dentists typically are not the greatest of teachers. We were selected for dental school based mainly on our manual dexterity and analytical skills, not on our ability to interact with people. We were taught to diagnose dental problems and to “fix teeth.” We were expected to perform procedures on patients who sit passively in dental chairs, not to involve them in learning, which is an interactive process. Consequently, most dental offices you see today are designed mainly for “doing” or “fixing” rather than for “teaching” and “learning.” I have made a concerted effort, over time, to gear my practice towards offering learning experiences for my patients that can empower them to take a large portion of their dental health into their own hands.

This may sound simple enough, but there are obstacles that work against the dentist developing a health-centered approach to their practice. For instance, if you are a new dentist starting out today, you are saddled with major debt. It is not uncommon for the new dental school graduate to have an indebtedness of $200,000, to which a return on invested capital including interest, as well as lost income while in school must be realized. Add to this the fact that, unlike a physician for example, who has hospital privileges, which includes staff, the dentist must set up and operate his/her own dental “hospital” with expensive equipment and quality staff. This financial burden puts pressure on the dentist to produce, rather than to take the time to further their studies and teach their patients. These realities are what tempt the dentist to feel the necessity to be concerned more with quantity than quality.


The dilemma that I face when recommending these restorations (which I have had placed in my own teeth) has to do with the intent residing within the oath I signed upon becoming a dentist which states, “First, Do No Harm…” in juxtaposition to the patient’s desire to have natural tooth color, which is understandable.  I know that when I drill off a lot of tooth structure I may be inviting a root canal treatment which could occur around treatment time, or delayed, maybe for years.  And a root canal treatment on a back tooth is not a guarantee of its safety for the future.  I have seen many back teeth fracture underneath the best of crowns requiring the tooth’s removal.  Now we’re looking at an extraction, root replacement implant and new crown.

Some of the new porcelain materials are stronger, look great and fit better than those of the past, however they haven’t as yet compiled the track record of gold which has been used for over 100 years.  However, in most cases, mercury amalgam fillings can be replaced with conservative cast gold restorations in a very inconspicuous manner.

I believe that it is very important to consider all parameters involved when making decisions concerning the health and longevity of one’s oral system, not only regarding safety in removing mercury amalgam fillings, but the type of materials used in replacing them, the quality of the dental laboratory, and the individuality of the patient.  I want to honor my patient’s desires, however I also want their decisions to be influenced by facts that will allow them to make a properly informed one prior to even taking the first step.

*Dr. McBride received awards for excellence in gold technology in dental school and has been trained by Dr. Richard V. Tucker as a member of the Richard V. Tucker Study Club.


“I trusted Dr. McBride’s judgment from the beginning in his dental recommendations.  I had a lot of cavities as a teenager and young adult, and first of all he taught me how to stop getting them. Then he restored my teeth with conservative cast gold restorations which he said would be least traumatic to the teeth nerves and the most long lasting treatment available if done properly. I guess they were in that they have kept my teeth strong and healthy for over 30 years and I have had no cavities, re-treatment of his work or root canals on any of my teeth since I started with him. I love my smile – you can’t see any of the gold –but what’s more, they will probably last a lifetime. Treatment that’s done right the first time pays off year after year and is one of the best investments I’ve ever made in my health. Thank you Dr. McBride.”  –Pam R.