From Hesitant to Confident: Communicating the Value of Zirconia Crowns with Ease – Transcript
[00:00:01] Welcome and disclosures
Thanks for being here after work hours. My name is Dr. Alex Otto. I’m a pediatric dentist, and I’m leading today’s session for Sprig on how we talk about zirconia crowns: going from maybe a little hesitant to presenting them with confidence. I’m really excited to be here with you tonight.
If you have any questions during the presentation, please put them in the questions box in GoToWebinar, and I’ll get to as many as I can at the end. I’ll also share my personal contact information at the end. It’s after work hours for everyone, so I hope you have a glass of wine with you as you listen. Let’s get right into it.
A quick disclaimer: I am not an employee of Sprig. I’m a private practice pediatric dentist. I receive an honorarium for teaching the course, and I’m on the Sprig scientific advisory board, but I’m not an employee. I am a board-certified pediatric dentist.
[00:00:56] Background, training and professional roles
This is my husband, Tim, and me. We took some new headshots a few years ago, and the photographer told us to relax for a second. We both relaxed at the same time, and he thought it was so hilarious that he made this photo of us. I still need to get it printed on canvas for our house.
I’m a private practice dentist in Austin, Texas. I’m also the president of the Texas Academy of Pediatric Dentistry, and I just joined the team at Texas Children’s here in Austin as the pediatric dentist on our craniofacial team. I’m also the founder of Kids Tooth Team Pediatric Dentistry, Kids Tooth Team Outreach and Alcan Dental Cooperative, which I’ll share a bit about in a second. I’m also a mom of two little ones; I’ll show you a picture.
I’ve been practicing for 12 years. I graduated from VCU School of Dentistry in 2013. I grew up in Naples, Florida, and went to the University of Florida. I went straight to dental school and thought I would like being a pediatric dentist. But as you know, enjoying being around kids is very different from being their provider and their dentist. So I decided to do a general practice residency to get faster and gain experience in all aspects of dentistry.
I went to the program at Denver Health. We saw a lot of kids in clinic, and I got to work with a board-certified pediatric dentist in the operating room and learn more about pediatric dentistry. I realized I loved it and that it was definitely what I wanted to do. But I was also about $500,000 in debt after all of that. So I practiced as a general dentist for a few years to see how I felt about being a general dentist who saw kids. I realized general dentistry wasn’t what I loved, and I ended up working in pediatric offices as a general dentist for five years before going back to residency.
I applied all over the place and picked the program in Anchorage, Alaska. It’s a super unique program, and I’ll tell you more about it during the presentation. It really shaped my philosophy of care in pediatric dentistry: how I approach treatment planning and care for our pediatric patients. That’s some of what I’ll share tonight, including how zirconia has played into it.
I’m really passionate about organized dentistry. I represent Texas on the AAPD’s Council for Advocacy, Access and Prevention. I’m the chair of the TDA’s Council on Professions and Trends and, like I mentioned, TAPD president. I’m also on our Southwest Society board and honored to be a fellow in some really great groups. I just joined the AAPD Safety Committee as their national private practice expert consultant.
I also treat the St. David’s Foundation patients in Austin; I’m their number one referral provider. That shapes who I am as a pediatric dentist, too. I’m in private practice, but I have a heart for public health. A lot of the patients we all see are kids with Medicaid and kids who are high risk, and that plays into how we treatment plan. The St. David’s patients I see often just moved to the United States and have never seen a dentist before. We need to be proactive about their care and treatment plan in a different way. We’ll talk more about that later.
I’m really honored to be a speaker for Sprig. I think my first class was in 2022, and I’ve loved being part of the group and learning from the other Sprig instructors. It’s a like-minded group, and I meet so many wonderful people at our Sprig Universities, including some of you. I also speak for CareStack, our practice management software, and for Elevate, the makers of SDF and some really minimally invasive treatment options. That matters in this lecture: we’re going to talk about zirconia crowns, but there’s a time and a place for zirconia and a time and a place for SDF. It’s about picking the right tools at the right time, and we’ll come back to that throughout.
[00:04:49] Practices, outreach and family
These are my offices in Austin and Michigan. We have four practices in the greater Austin area and two in Michigan; a couple are under construction right now. We started the Michigan practices with one of my best friends from residency in Alaska, so we have Kids Tooth Team in a couple of states. This is our personal brand of pediatric dental offices.
We also have a nonprofit outreach program in Texas. As the St. David’s Foundation upgrades its fleet of dental vans, it donates a van to a nonprofit, and a few years ago we were one of the nonprofits that received one. We partner with local elementary schools in Austin and provide free dental care. To date, we’ve donated over $700,000 of free care to kids in need in Texas. I’m super honored to have this van and the ability to serve kids who really need us. If any of you have a Texas dental license, I would love to have you on our van helping out with these kiddos.
Tim and I also founded Alcan Dental Cooperative, a pediatric partnership organization. We partner with independent pediatric offices to help them stay independent, keep ownership of their practices, deliver excellent care, keep high standards and be the best pediatric nurse they can be for their practice and community. We take over a lot of the business management: payroll, accounting, HR, the things that stress all of us out, so they can focus on being pediatric dentists. We’re a kind of anti-DSO. We feel pediatric dentists should be able to own their own practices, and we’re passionate about helping other pediatric dentists do that.
I’ve been honored with some incredible awards, the ADA 10 Under 10 and Incisal Edge 40 Under 40, but honestly I’m more honored to be the local favorite pediatric dentist in our community.
This is my family, and this is the phase of life I’m in right now: lots of big feelings and emotions all the time. Max is three and Adeline is 20 months. They’re actually pretty cute most of the time. This was Max’s new best friend, a skeleton named Skeleton Cowboy. He went everywhere with us for about two weeks and slept in the bed with my son, so we have all these crazy videos of a skeleton coming out of the bed in the middle of the night. Three-year-olds are weird, but I love them, and they’re so fun.
I know a lot of you are parents, too. Being a mom really shapes my lens when I’m talking to families. It makes me think differently about how I treatment plan, and about what I’d want healthcare providers to tell me and how I’d want them to present options.
[00:07:25] Why zirconia crowns
I’m really excited to talk about zirconias. They’re one of my favorite things to do in the practice, something I’m really passionate about, and something that matters in the community where my practices are. I’m excited to share how I communicate about them with our families.
These kids are the reason I do this. They leave my office healthier, their disease is well managed, the parents are happy and they look beautiful. I do stainless steel crowns, composites, SDF, everything. Zirconias are probably my favorite, because I’m always so happy with the results and parents are so happy. This is a product that lets me live my philosophy of care and my standards of care every single day.
It’s also a huge practice builder. That is not the reason I do it, but a lot of us own businesses. So which solutions are we offering patients that are wonderful, let us live our standards of care and are also great for business? I’ve personally placed over 1,600 Sprig crowns in my practice. That revenue has come to over $600,000 for me personally. Across four of our locations, with all of our associate doctors, we’ve done over $1.3 million in zirconia crowns.
I didn’t even know these numbers until I ran some reports for this presentation. I was like, wow, I had no idea. It’s just part of my philosophy of care. […] That’s an important part of the conversation, too.
These are the reasons I do zirconia crowns. I want these kids to have beautiful smiles they’re proud of. I want them to be healthy. I want to do things I feel good about, without compromising my standards or doing things I know won’t last or won’t be good long-term solutions. Zirconias are one of the biggest ways I do that in my practice, so I’m really proud to offer them and to talk with you about them.
[00:09:35] Poll: what has made you hesitant?
Before we get started, we have a couple of poll questions. Let’s open the first one: what has made you hesitant to recommend or place zirconia crowns in your practice? Jennifer, if you can share the poll with everyone, we’ll pop that up. I may not be able to see it on my side.
Host: They’re answering right now.
Perfect. We’ll give you a few seconds. There’s no wrong answer to any of these poll questions. I’m just curious what has given our audience pause when considering offering these. I’m not seeing anything on my end; is there a way to share?
Host: No problem. 38% said they’re not fully confident placing them clinically. 14% are unsure how parents will respond and whether they’ll want them. 14% are uncertain about long-term success or evidence. 43% said they’re not covered by insurance or families can’t afford them. And 14% said it’s hard to implement a new system or workflow in their practice.
Perfect. That’s honestly about where I thought we’d fall, and it’s exactly what we’re talking about today. I’m excited to share solutions to all of those concerns. Again, if you have questions along the way, put them in the question box.
[00:11:10] Session goals and disclaimer
First, I want to take a few minutes to clarify your standards of care and your philosophy of care. I want to be crystal clear: there’s no judgment and no shaming. The point of talking about our standards is to give you the insight and the exercise of asking yourself: what are my standards of care? When do I place a filling instead of a crown? When do I offer white or silver crowns? Sharing my philosophy doesn’t mean anyone is doing anything wrong. I think you’re all amazing dentists. It’s about having that internal dialogue, putting pen to paper and clarifying your standards.
I also want to talk about the biases we have about our own patients, the biases we have about the product and what zirconia crowns are, how to present with clarity and confidence, and some options for calibrating your team. Implementing systems or any new product in your office is a lot of work, and I totally understand that. In our offices, I personally beta test anything new, any new cement, product or AI technology, in all of our practices before we roll it out to our Kids Tooth Team or Alcan practices. So I know how much work it is to implement anything new, and we’ll definitely talk about that today.
This is all food for thought. It’s not meant to make anyone feel a certain way about what they’re currently doing. It’s to give some insight into what I do, and for you to think about what your biases might be without even realizing it.
[00:13:03] Clarifying your standards and philosophy of care
Let’s first talk about clarifying our standards and philosophy of care. When I was alone in private practice, I didn’t have a formula. I couldn’t quickly write down my philosophy of care: when I’d do certain treatments for some patients and not others, or when I’d offer certain treatment plans.
It wasn’t until associate doctors joined my practice that I realized we all do things so differently. We come from different backgrounds and experiences, and that shapes who we are as pediatric dentists. In a group practice, building trust with patients and families meant we needed a shared philosophy of care. When do we do SDF? When do we do a zirconia crown? Which kids are we sedating? I wish I had done this sooner, when it was just me. Once I had my standards and philosophy of care on paper, it was so much easier to talk to families.
“Hey mom, we don’t do a filling in these situations because of X, Y and Z. This is when we do general anesthesia instead of oral sedation.” Having that detailed in my mind was freeing and clarifying, because I knew my standards and what I live by. If that didn’t meet a family’s expectations, there were no hard feelings, but I also couldn’t compromise my standards and what I felt was right for the family. It makes for an easier conversation and takes the emotion out of it: these are our standards, this is what we do and what we’re comfortable with. Not everyone has standards as high as our practice does, and we’ll talk about some coaching around that.
So think through what your standard of care is. Are we just offering products? Are we choosing solutions because it’s what Medicaid covers: “I see Medicaid patients, so I have to use this product”? Is that our standard of care? Or are we offering the most biocompatible, best material that looks the most beautiful for our patients? My standard of care is that I want my name on this. I want to do things I feel good about and know are the healthiest for my patients.
Is our standard of care to use whatever material is least expensive? Or are we offering solutions that may cost a little more but that we know will last the longest, be the most durable and give families the best long-term outcomes? Is our standard to default to the most minimally invasive option at any cost? Are we avoiding oral sedation or GA because we’re afraid to tell families it’s something their child might need, so we default to what we think is the least invasive, most conservative option? Maybe that’s not what’s best for that child in the long run, and it won’t actively manage the disease in their mouth. We want these kids to have teeth that let them eat, chew and speak, and beautiful smiles they’re proud of.
Are we using products that just came on the market and probably haven’t been tested as much as they should have been before going into kids’ mouths? Or products that are tried and true, have been around for 15 years and are the standard of care for white crowns? What’s actually driving our treatment decisions?
So many of us pride ourselves on being evidence-based dentists, but then the emotional part comes in. I don’t want this patient to have to pay. I don’t want to come off as aggressive. I want to be the least invasive, most conservative dentist in my community. So we avoid some conversations, soften our recommendations and don’t always tell parents the full truth, because we’re afraid of their reaction. This is something I have to tell myself daily: don’t use minimizing language, and tell the full truth about what’s going on.
Whenever a new associate joins my practices or a new practice joins Alcan, I spend a couple of days listening and observing. How are we presenting things? How are we talking to families? What language are we using when we present treatment plans? This is universal among all of us, and I know because I live it every day. None of these things are necessarily wrong, but they aren’t a philosophy of care. We all need to be aware of them as we present treatment plans.
[00:17:46] How Alaska shifted my mindset
I want to share a bit more about my philosophy of care. I was a general dentist for five years. I was the person asking why all these pediatric dentists were putting crowns on everything. They’re crazy. It’s just a little cavity; you could totally do a filling. It wasn’t until I went back to pediatric residency, specifically in Alaska, that my mindset completely shifted.
I really understood managing disease versus managing a lesion. These kids had to fly from their villages to Anchorage for care, then fly back the day after GA, maybe never to see a dentist again. So which treatments do we pick? The ones we know are the most definitive, will last the longest and have the least risk of catastrophic failure or the child experiencing pain. We’re not going to watch an enamel lesion on a kid under GA, because there’s no one to watch it. We treat it definitively.
In Alaska, I realized: doesn’t every kid deserve that? Why are we doing things that aren’t the most definitive and don’t have the best outcomes, even for the kid who lives down the street from me? No kid wants to go to the dentist more than they have to. No parent wants to pay twice for treatment. I never want to put a kid to sleep a second time if I can avoid it. Treating patients in these remote areas made me realize that the kids in our own communities need to be treated with the same thoughtfulness.
That shaped my public health mindset and how accurately I assess caries risk. It doesn’t matter if a child lives down the street in a nice neighborhood and has PPO insurance. If they have 12 cavities, they’re high caries risk. So what are our biases as we think through our patients? We’ll talk more about that today. I love Alaska; if you ever go, I’m happy to help plan your trip. It was a beautiful, incredible experience.
[00:19:59] Do it once, do it right
Alaska taught me that the goal in pediatric dentistry, and in my philosophy of care, is doing the right thing at the right time with the right clinical judgment and the right tools. We don’t want to SDF everything all the time. We’re not going to SDF something because we don’t want to deal with that family, or because the kid has challenging cooperation or behavior. We don’t need to zirconia everything, and not every kid needs GA. It’s about looking at the family, the child and the lesion, taking it all into account and having all these tools in our toolbox to provide the best care.
My personal philosophy in our offices is: I want to do it once and do it right. I don’t want to treat this tooth again. I don’t want this kid back in my chair for GA, or for a filling that popped out. […] I want treatments that I know will have a high success rate and do a good job.
Sometimes, for a cooperative kid, that’s a class II composite under nitrous. If the child allows great isolation and is cooperative, and a filling pops out, I can redo it under nitrous; it’s not a huge deal. But if a filling pops out and I had put that kid to sleep under anesthesia, I don’t want to look that mom in the eye and say I didn’t pick the right […] I really want to do it right the first time.
Here’s how I think about minimally invasive: it’s not about doing less. Sometimes it is. Sometimes we’re preserving tooth structure, or avoiding sedation because that’s what a family wants or there are medical reasons we can’t sedate. But minimally invasive really means choosing interventions that preserve the overall health of the child, not just a little tooth structure. I want to know what’s best for this child’s body, their life and their family. Are they driving three hours to see you? What treatment would you offer them that might differ from what you’d offer someone who can come back next week?
Minimally invasive doesn’t mean watching and waiting indefinitely. I think that’s misunderstood in conservative or minimally invasive dentistry. We’re not watching a lesion past the DEJ forever, because we know it’s going to reach the pulp. I truly believe that delaying care without a plan in place isn’t conservative. It’s supervised neglect. I’ll show you some pictures of what I mean. If we don’t have a plan for these families and aren’t actively managing their disease, we’re just supervising neglect.
These kids hurt, and the last thing I want is for a child to be in pain or uncomfortable. As you know, they don’t always know how to say they’re hurting. It’s just normal to them that it hurts every time they chew, or that pain keeps them up at night. If we’re not advocating for them and telling the family there’s active disease we need to manage, they won’t get the care they need. I’m passionate about making sure families are informed and part of the decision-making, but also about telling the truth so kids get the care they need. So I’m big on managing disease, not just managing a lesion. It’s not a formula; it’s a philosophy. Minimally invasive means focusing on what’s best for that child and family in the long run, so we can restore form and function.
[00:23:15] Poll: fillings vs crowns, and managing disease
Next, we’re going to talk about fillings versus crowns. When do you place a filling instead of a crown? What’s your thought process when you see a certain lesion on an x-ray in a certain kind of kid? Again, zero judgment and no wrong answers. I placed only fillings for five years before I went back to pediatric residency, so I’ve been in every practice setting. I’m just curious what you think.
Host: Dr. Alex, 15% of attendees say they usually do fillings first, 35% do crowns only for large multi-surface decay, 15% do fillings with N2O or OCS and crowns under GA, 15% adjust when parents request no crown, and the largest response, 70%, is case by case.
Perfect. That’s definitely the answer I get when I ask my associate doctors and the doctors who join our Alcan practices. So as we think through this, we want to be evidence-based. What is our philosophy of care?
Say a kid comes in with a lesion like this. What I tell families is: you have a cavity in the first layer of your tooth. I want to be super transparent, and I’m not trying to use minimizing language. If we say, “There’s a little spot, there might be a cavity starting, we’ll just watch a couple of things, don’t worry,” families hear it in one ear and out the other: great, we’re doing good, no problems. But we know this tiny enamel lesion is going to reach the DEJ in a month or two. In my community, I’ve seen lesions like this reach the pulp in six months.
So how are we managing this lesion? I think most of us would say we’ll put some SDF on it, apply fluoride varnish, see them in six months and take new x-rays. That’s pretty standard for how we as pediatric dentists would approach it. But are we managing that lesion, or managing this kid’s mouth? What mouth does that lesion live in? A child who has four lesions well past the DEJ and three other incipient lesions in the enamel. How do we approach this case so we actively manage the disease and not just one little lesion?
I teach a lot for the AGD in general dentistry, and that’s the biggest thing I focus on to help general dentists think like pediatric dentists. We’re not just saying this size lesion gets a filling and that size gets a crown. There’s so much more to take into account. Is that incipient lesion on a tooth that’s the color of a Cheeto? Does it have a nerve stuck in it? Am I treating it under general anesthesia or under nitrous? We’re looking at the whole picture and the mouth that tooth lives in.
[00:26:27] The evidence on fillings vs crowns
I had to have ChatGPT do this math for me because I couldn’t. Evidence shows the success rate for interproximal or multi-surface fillings is lower than for crowns. Some studies report success rates as low as 60% for interproximal lesions, and even lower for bigger lesions. So, food for thought: if we’re doing eight interproximal composites, each with a 60% success rate, the overall success of the treatment is 1.7%. That means there’s almost a 100% chance something will fail. A composite will fall out, a tooth will break or abscess; something will fail.
This is a kid who had all their treatment done two weeks ago. Had I seen them first, we could have just done crowns. Now we have to do pulps and crowns, because the filling was so close to the pulp that the pulp is responding. The success rate is so low, and with eight of them, it drops drastically.
General dentists can’t always wrap their minds around this, but I do not do any MODs in my practice, no matter what. Even with two small lesions just past the DEJ, I’m not doing an MOD, because if each lesion has a 60% success rate, the success of the whole tooth drops to 36%. That’s a high failure rate. I’d be upset if I got a 36% on a test, and I don’t want to put something in a kid’s mouth that I know has a huge chance of failure.
This is what happens, even when fillings are done well. You can do a great MO, and these high-risk kids will get a DO in six months. Even with an okay MOD, certain teeth, like first molars, aren’t great candidates, because they’re so close to the mesial pulp horn. If we did eight MODs, there’s a 100% chance of failure.
If we think through this as the evidence-based scientists we are, what is the evidence showing? Study after study shows crowns have a better success rate and are less likely to develop long-term problems than fillings. Our AAPD guidelines support using crowns in high-risk children, period, and especially in high-risk children under GA. There’s so much evidence behind this that I often wonder why we’re doing fillings.
I say this as someone who does fillings. If I have an occlusal lesion on a kid who will tolerate nitrous, or an oral sedation on a cooperative kiddo where I can get good isolation, I still do fillings. But on high-risk kids with eight or 12 lesions under anesthesia, why would someone do a filling instead?
[00:29:24] Approval addiction and AI radiographs
The biggest reasons I see among my doctors and the groups we work with are something called approval addiction, which we’ll talk about, and a desire to be seen as conservative. We don’t want to come off pushy or aggressive. We want to save families money, be nice and come off as pleasant. These emotional reasons for recommending a filling over a crown aren’t always in the best interest of kids.
Think back to residency: we would never have been allowed to place fillings in these spots. Somehow we get into practice, and even though these kids would be high caries risk if we did the caries risk assessment like we used to on every kid, our philosophy changes. We adapt to how parents perceive and react to what we say.
So my plea and my challenge to you is not to give in to approval addiction. What is it? It’s a subconscious desire to gain parental approval and avoid conflict, which often leads clinicians to minimize findings, soften recommendations or delay necessary care. “Don’t worry, mom, it’s a little spot. We’ll keep an eye on it. Let’s wait until it starts hurting; maybe it’ll fall out soon. It’s hard to tell if it’s a cavity.” We watch and wait because we want them to like us and not feel stressed, worried or pressured. So we minimize.
I have to catch myself every day. I start to say “it’s a small…” and switch to “it’s a cavity in the first layer of the tooth.” I train people to do this, and I still say these things. So why are we presenting things in a way that doesn’t give the full truth? Why are we telling parents what they want to hear instead of what their child actually needs? This is a big problem in all of our practices. I see it every day in myself, my associate doctors and my partner and owner doctors.
Something that’s really helped our practices is AI technology for radiographs. Instead of me diagnosing, it’s the AI overlords who have diagnosed these cavities; I’m just here to deliver the news. Whatever it takes for you to feel confident explaining what a cavity is.
“Hey mom, we have AI radiographic technology. It’s great because it color-codes the cavities, so I can explain them better, and it helps make sure I’m not missing anything.” That’s the key for me: I’m not here to diagnose more. I’m here to miss less, and AI helps me do that. I want to make sure your child gets the care they need. “Let’s come over here and take a look. […] That’s the purple part you see here. Even a small spot, like tooth S over there, clinically just looks like a little chip, but there’s an abscess there. The red and purple spots are really bad; that can mean the tooth is already infected. Even though we don’t see many of these cavities clinically, the x-rays show these hidden spots between the teeth are actually really big. So let’s talk through how we’re going to take care of this.”
This is one way I’ve helped our doctors avoid approval addiction and make it easier to explain and present findings. It also holds us accountable. I’m not missing anything when there’s a big red mark there, and it’s easy for me to track my doctors and see what’s going on in our practices. So my first plea is to think about approval addiction and why we say the things we say.
[00:32:50] Poll: who gets offered zirconia?
The second part is about our patients, the biases we have and why we feel the need for approval in our practices. As you think about your patients, here’s a last poll question: what’s crossed your mind when you didn’t offer zirconias?
We’ve talked about when we offer fillings versus crowns, which in my practice is honestly the biggest issue. It’s not white versus silver; it’s “why can’t you do a filling instead of a crown?” We talked through some scripting there, and we’ll talk more in a bit. But once you’ve decided a tooth needs a crown, based on your philosophy of care, when do you offer white, silver or both? What are you thinking about as you decide who gets the offer of a white crown?
Host: Dr. Alex, 50% of attendees say patients won’t pay if insurance doesn’t cover it. 17% assume families are okay with silver if SSCs are already present. 0% chose avoiding making them feel bad about cost. 13% don’t want to seem pushy or like they’re upselling. And 21% always offer zirconia.
Perfect. The most common response I get is “my patients don’t want this; they can’t afford it.”
[00:34:14] Every patient gets the option
My challenge to you is to really think through who gets the option. In my practice, every single patient who is treatment planned for a crown gets the option of white or silver. We’ll talk about a conversation framework for that in a bit, but every patient gets the option: “Hey mom, we need to do some crowns. We have white crowns or silver crowns, and I’m happy to do whichever you prefer. I just want you to know it’s a choice, and I want you to see pictures of what they look like.”
That’s how I sell zirconia crowns: I don’t sell them at all. I just offer them as an option. If you start offering them, do exactly that. Tell them you have white or silver crown options, then stop talking and let them ask questions. […] What I see and hear from doctors in our group is: “We have white or silver options, but the white ones aren’t covered by insurance, they’re really expensive, sometimes they break or come out, they take me longer, I might need a different sedation option,” and the list goes on. Don’t say all of that. Just say, “We have white or silver crown options. What would you like to do?” and see what they say.
You don’t have to talk about finances. If they say they’d love the white crowns: “Wonderful. Let me get that treatment plan together. When you check out, my financial coordinator will go through the options and how we can make sure your child gets the care you want.” That’s all we have to do.
This is what I show every family that comes into my practice. So, for a kid with these x-rays, who gets the option of white or silver? How do you decide? “You get the option of white crowns, but you don’t. Your insurance covers it, so I’ll offer it to you, but yours doesn’t, so I won’t. If you have Medicaid, I assume you can’t afford it, so I won’t even offer it.” What’s the thought process behind that?
I get it. We don’t want to make families feel bad, and some of them can’t afford it, which is 100% okay. We’re not being pushy. If a mom comes back and says, “That’s just not in our budget right now,” my office says, “I totally understand. Honestly, white and silver are both good options. I just wanted you to know it’s a choice and what it looks like. I want you to be happy at the end of the day, and I’m happy to do either one. I just feel you deserve to know it’s a choice.”
For us, every kid gets the option. It doesn’t matter what their insurance is or what neighborhood they come from. I feel super passionate about offering this not just to the kids we think can afford it. You have no idea what’s going on in those families. We accept Medicaid in all of our practices, and I have just as many Medicaid families who pick this over another option. Assuming what’s important to a family, what they prioritize or whether they care enough is something you’re putting on yourself instead of letting them make the decision.
As a mom, I would honestly be upset if a provider didn’t offer me a solution that was more beautiful, lasted longer and had better long-term outcomes for my child because it cost a couple hundred dollars more. Offering it as a solution isn’t salesy, and it isn’t a guilt trip: “No worries, mom, I’m happy to do the other one too. I just wanted you to know it was a choice.” I truly believe kids deserve beautiful smiles they’re proud of and the ability to eat, speak and live pain-free. Even more passionately, I believe they deserve healthcare providers who advocate for them, because how well we communicate with families determines whether they get the care they need.
[00:38:13] Informed consent without overwhelm
If we confuse families or overwhelm parents with treatment options, they don’t know how to choose. I believe informed consent does not mean informing them of every single possible option. We pick options that let us live our standards of care, are best for this child, manage their disease and restore form and function.
For this kid, someone could say we could extract all their teeth or SDF all of them. Those are technically treatment options, but would you actually recommend them? I’m not going to put strip crowns on these teeth, because I know they’ll break and it won’t work. In my offices, if there’s caries on the front teeth, we do zirconias or we extract them. From canine to molars, it’s white or silver crowns if we’re doing GA. If a kid can tolerate treatment under nitrous or oral sedation, I’m open to composites in certain situations. We’ll talk more about this framework, but it’s about setting your standards for your kids and advocating for them.
[00:39:18] Myths about zirconia crowns
A lot of us have biases about crowns, and some of you mentioned this in the first poll: “I don’t know about their long-term success. I’ve heard things about zirconias.” These are the most common concerns I hear when I ask our doctors why they aren’t offering them.
Myth: they break or fracture easily. I promise you this is not true. Having placed thousands of them, the only times I’ve had a zirconia crack are when I left a ledge. It happened a couple of days ago: I left a ledge, it cracked as I was seating it, and that was completely me, not the crown. If the technique and prep are done correctly, these are incredibly strong. Zirconias have very high compressive strength but not high flexural strength, so how we prep and seat them is very different from an SSC. Once you learn the technique, which is really simplified, it’s straightforward. We break it down well at Sprig University and in a lot of our other webinars, so I won’t go into prep technique in this webinar. The only times I’ve seen them break are when I left a ledge or didn’t prep correctly. I still tell families not to chew on rocks, but I’ve never had a kid bite into something and break one.
Myth: you have to pulp the tooth. This was true of previous versions of crowns. The occlusal surface was much thicker, so iatrogenic pulp damage was more common. That doesn’t happen anymore. For the last six years, I’ve used only version two of Sprig crowns. In this version, the occlusal surface is very flat and needs minimal occlusal reduction. A lot of competitors still have a ton of occlusal anatomy in their zirconias, so you have to reduce more and you risk pulping the tooth. I have never had to pulp a tooth I didn’t intend to pulp based on caries reaching the pulp.
With Sprig zirconia crowns, you’re only removing the enamel. Think back to the filling conversation: with a filling, I remove the decay completely so the filling will bond, and you’re way into the dentin. So a zirconia prep actually cuts less deeply into the tooth than most fillings. You’re really just removing enamel, nowhere near the pulp, if you prep correctly.
Myth: you can’t place them side by side like SSCs. Definitely not true either. One of the best things about Sprig is the space-loss version of the crowns. Whether there’s space loss due to caries or you’re seating several back to back, it works. Almost always, if I do A, B and C together, one of them will be a space-loss version to buy myself a little room. They work wonderfully. I do two side by side all the time, and I do second molars all the time.
Something I didn’t put on the slide: people worry the six-year molars will get stuck on them. I don’t think I’ve ever had a zirconia get stuck on a second molar, but I have had SSCs get stuck, and some kids have ectopic eruption with no crown there at all. So I don’t see it as a problem in my practice.
Myth: the prep takes too long. I do Hall crowns all the time in my office, so I can literally do no prep and place a silver crown. People worry that the zirconia prep takes forever. For a single tooth, I can do a zirconia in the same time as an SSC. For a full-mouth case, 12 zirconia crowns under GA, I’ll add 15 to 30 minutes to my GA time just to give myself room, but it’s really only taking 10 or 15 minutes more. Once you get the prep down, it’s super repeatable and not a complicated prep. We teach it at Sprig University, and I’ll share more information on that.
[00:43:18] Aesthetics, biocompatibility and the Sprig facility
We come in with these biases or things we’ve heard about zirconias, but the reality is they’re so biocompatible and beautiful that parents can’t even tell there’s a crown in the mouth. I tell parents, “Honestly, I’ve never had a parent be upset or wish they hadn’t picked this.” The only time parents come back is when they wish they’d picked white instead of silver. They look beautiful, and you’ll never be able to tell there’s a crown there.
They’re also very plaque-resistant. This kid obviously isn’t brushing any of their teeth, but the zirconias just resist plaque, and the gums heal so beautifully around them. It’s incredible.
The Sprig design and product itself is superior. I attended their grand opening last month in California, the first time I got to tour the facility and see how the crowns are made from start to finish. The most amazing thing was seeing people sitting there hand-painting every single crown we put in kids’ mouths. I thought much more of it would be automated or done by machine, but there’s so much human touch in each one. When they’re done, someone inspects each of them to make sure they’re perfect before they’re sent to your offices. It was really cool to see.
[00:44:45] Scripting and objection handling
I want you to present this with confidence and feel confident, so let’s talk about scripting. Like I said, in my office I don’t really get pushback on white versus silver. I’m not selling it. I’m saying, “This is a choice you have. Many other offices don’t do white crowns. My office does, and I wanted you to know it’s an option.”
The objection I field most in my offices is: why can’t you just do a filling? Why does it have to be a crown? The first thing I say, and our team is coached on this all the time, is: “Tell me more about that. Can you tell me what your concerns are about a crown? I’d love to understand that more.”
I also coach our team that just because parents ask why doesn’t mean they don’t want it. They’re trying to understand more. As doctors, we sometimes get defensive without realizing it, as if they’re questioning our authority or our treatment planning. That’s not what parents are doing.
I learned this firsthand. My son hurt his knee and we went to urgent care. The doctor said, “I think we should take an x-ray,” and I was that mom: “How much radiation is that? Do you really feel it’s necessary? Tell me more.” The doctor backed off completely: “We don’t have to. If you don’t want to, we can watch it and wait.” We got home and he was still hurting, so the next day we took him to the children’s hospital. That doctor said, “You have to take an x-ray. It’s the only way we can see what’s going on in his knee.” And we said, “Okay, thank you. I appreciate you saying that.” I wasn’t saying no to the x-ray. I just wanted more information and to understand my options.
So when a parent asks why their child needs a crown, they’re not saying no; they want more information. Don’t be defensive. Say, “That’s a really great question. In these situations, a filling won’t work for this tooth. Baby teeth are very different from adult teeth. The layers are so thin that cavities progress really quickly, and fillings just don’t bond as well. For these teeth, a crown really is the option that will last the longest, do the best and minimize the chance we have to retreat in the future.” Again, always start with “Tell me more about that.”
Parents will also say crowns seem expensive and ask how much they cost. I usually say, “Crowns are actually really affordable. They’re a fraction of the cost of an adult crown and much less expensive in the long run. Fillings in baby teeth typically last about two years on average before they need to be replaced or something happens, whereas a crown almost always lasts the lifetime of the tooth. […] Doing it right the first time actually saves you money in the long run.” I usually add that a silver crown costs about the same as a filling, and if they’d like a more aesthetic white crown instead, we’re happy to present the finances for that. It’s their choice what treatment they want for their family.
Sometimes parents won’t tell you directly what their objection is, but asking “Tell me more about your concerns” at least gives you a direction: expense, safety or that it seems aggressive. If a parent says, “That seems aggressive; I don’t want to remove so much tooth structure” (a mom literally emailed me this yesterday), here’s how I explain it: “A baby tooth crown is a totally different procedure from an adult crown. We place it in one easy visit. The goal isn’t taking away more tooth structure. It’s preserving what we have left as best we can, and the best way to save that tooth until it’s ready to fall out is a crown. It’s the most durable and most protective option, and the cement that holds the crown in place is actually medicine that helps protect the tooth. It’s a protective layer that keeps the tooth in as long as possible.”
Some parents worry it sounds like a big, painful procedure. That’s when I say, “This isn’t the same procedure as an adult crown. You’ll be surprised how easy it is for them. We’ll make sure they’re comfortable, and let’s talk about some ways we can do that.”
[00:48:44] Leading with clarity and showing results
So lead with confidence and clarity. When do you do a filling? When do you do a crown? Who are you offering these to? Once you have this on paper and in your head, these are the kids you’ll offer this treatment to, and it’s easy for you to say. It’s also easy for your team to say: “These are situations where we don’t do fillings, because that doesn’t meet our standards and quality of care. We have very high standards in our office, and we don’t want to do things with a high failure rate, because we want to do what’s best for you and your family. Our standard of care in this situation is a crown. We have white or silver crown options, and I’m happy to do whichever you prefer.” Once your team hears you say that, they’ll understand and be able to repeat it to families.
“Why can’t you do a filling?” is so common in my practice that I made little flyers to hand out: what’s the difference between a filling and a crown, and why are we recommending this? These are things you can do in your practice to get buy-in and case acceptance, along with explaining what you would do for your own child and the long-term benefits of doing something once, with the highest success rate and the lowest chance of retreatment.
These are photos of the crowns I’ve placed in my office. As you start doing and offering more of these, take before and after pictures. When I first started, I had every kid come back for a two-week follow-up because I was worried. It was new, and I wanted to make sure everything was healing okay. I was always blown away by how beautiful it looked at two weeks, so I started documenting all my cases. It’s really nice for parents to see that.
These typodonts are great. Sprig has some, or you can make your own. It’s literally just showing them. I don’t know what parents think we mean when we say silver, but you’ve all had this happen: they come out of treatment and say, “Oh, it’s silver.” Yes, that’s what I meant when I said silver. They ask, “Is it the white kind of silver?” No, that is not what silver is. So now I just show pictures: this is what a zirconia looks like, and this is what the others look like.
If you’re talking about UCR, the difference between an SSC and a zirconia is only about $100 in my office. Whether insurance covers it is a different matter, but it’s really a minor difference in cost.
Get to the heart of what parents’ goals are. Do they want the safest, the healthiest, the least traumatic, the least invasive or the most cost-effective option? Whatever their goal is, there’s a way to tie zirconia to it. It’s the most biocompatible and safest material we can use. It’s the healthiest and most beautiful. I want to avoid trauma too; I don’t want them to need repeat treatment time and time again, so let’s do this right the first time. To me, it’s the most minimally invasive thing we can do in these situations, because we restore once, restore form and function and manage the disease in the most effective way. And it’s cost-effective in the long run.
[00:51:35] Presenting a full treatment plan
I’m running a little behind, so I’ll move through some of these. Back to these x-rays: of course, if this were a cooperative kid, with all the sedation modalities at our disposal, maybe we’d SDF A, T and K, do composites on J and S, and crowns on I and L. But if we present it to a parent that way, it’s very confusing.
So when I present a plan like this, I say: “Hey mom, we have cavities in multiple areas of the mouth, and there are a couple of ways we can treat them. If they’re going to be awake, we can use laughing gas or a light oral sedation. They’ll still be awake for the procedure, and it could take two or three visits depending on how they do. Honestly, for some kids, by the second visit the jig is up. They’re not as excited to be here, so I can’t promise we’ll get all the treatment done in a way that keeps them safe and comfortable, but I’m happy to try. If you’d rather they be asleep and comfortable so we can get everything done at once, that’s a great option too. What are your thoughts, and how are you feeling about that?”
If they want to avoid GA and go with nitrous or oral sedation, then I talk about specific treatment options: SDF, maybe a couple of fillings, some crowns. If they choose GA, every single one of these teeth gets a crown. I’m not putting a composite on a high-caries-risk tooth in a kid under anesthesia, and this child is high caries risk. It makes it easy because our rule is that we don’t do composites under GA. I’m not risking putting a child to sleep a second time or looking a mom in the eye to say a filling popped out and we have to put them to sleep again. That’s our standard and our philosophy of care.
It also makes things easy for the kid who spits at you after fluoride and somehow kicks you from a horizontal position: “Hey mom, we’ve got cavities in all four areas of the mouth. That’s a lot to ask of a four-and-a-half-year-old. I really feel the safest way for them to be comfortable, and for me to do a good job and do things that last, is to have them asleep and get it all done at once. They’re comfortable, you only take off work once and they only miss school once. Would you like white or silver crowns?”
This is so common in our community. These kids are four years old, it’s the first time we’ve taken x-rays, and this is what I see. It’s a very common situation in my office, so that’s when I pull out the pictures and show families their choices. Getting to the heart of what’s important to each family is the key.
“I don’t want anesthesia.” “I don’t want a crown.” Tell me more about that; I’d love to understand so we can talk it through. I also tend to ask, “How are you feeling about that?” or “What’s your gut reaction?” rather than “What do you think?” Our brain says one thing, like “yes, they’ll probably be safe under anesthesia,” but how parents feel is very different. So I ask how they’re feeling about the options we discussed. That lets us get straight to their concerns and talk about them while they’re in the chair.
New doctors fresh out of residency will literally have my dental assistants print 17 different treatment plans. It’s overwhelming to tell a mom, “We could do SDF here, a filling here, a crown here. We can do a white crown or a silver crown. We can do it under nitrous, oral sedation or GA, but under GA we won’t do fillings, only crowns.” It’s crazy and overwhelming. We can’t expect a family to understand the nuances of disease, caries risk and management in a short amount of time.
So we present only options that live within our standards of care and that we feel are best for the child. If a child is obese and has huge tonsils, I won’t offer oral sedation, because it doesn’t meet my safety criteria. In the same way, if a child has eight lesions, is high caries risk and we’re doing general anesthesia, I won’t offer fillings, because that doesn’t meet my standard of care. Think through why we do the things we do.
[00:55:42] Closing challenge and calibrating your team
My challenge to you is to recognize and reset. We all come in with our own biases, and a lot of our decisions are emotionally based. We’re human; that makes total sense. But reset and reframe how we talk to families and present treatment options: how we talk about zirconias, SSCs and fillings versus crowns. Put your philosophy of care on paper, know why you do what you do and commit yourself to excellence. Kids deserve high-quality work that lasts and doesn’t need to be repaired and retreated time and time again. I truly believe that. So invest in your learning, equip your practice, pick the right cases, and stay consistent and visible. That’s what will let you communicate with confidence and present these products.
I’ll speed through this because I’m a little behind, but I’m happy to share it with you afterward. The important thing is that it starts with you. If you’re hesitant or not confident about any new technique or product, your team will sense it and won’t recommend it or talk about it either. For us, this isn’t about adding a new product. Everything we do is about protecting our standard of care. That’s why I got Overjet: I want to protect my ability to tell families the truth about what’s going on in their child’s mouth in a way they can understand. That’s why I offer zirconias.
When everyone knows how to communicate, front desk, RDAs and doctors, families feel the alignment and we get buy-in. You set the tone. Your front desk should know that you do these. If someone calls and asks, “Do you do white crowns?” they don’t just say yes. They say, “Yes, and our doctor is amazing at these. They look beautiful. We’d love to have you come in for a consult.” Your RDA knows it too: “Dr. Alex is the only one I’ve ever seen do these crowns. No other practice I’ve worked at does them. They look beautiful.” Your office manager knows as well.
Don’t feel bad about having your team hype you up. That’s what they should be doing: “Our doctor is amazing at these. She’s done thousands of them, and she teaches other doctors how to do them.” I tell parents I’ve literally never had a parent regret choosing a zirconia. They look beautiful, and they help us meet our standards of care.
We already talked about using the phrase “Tell me more about that” in your practice. It doesn’t pressure a parent; it opens the door to more conversation. You know how you tell parents something, they leave as if you didn’t say anything, and then they ask the RDA all the questions you just answered? Your assistant should be able to communicate with confidence and know why you use these crowns: they look beautiful, they’re the strongest material, and it’s what I would want if my child had a cavity. And then hyping up the doctor: our doctor is the best at these, and this is a really great choice. That helps families walk away feeling confident they picked the right thing for their child.
We have preset explosion codes, so for any crown we treatment plan, the codes automatically include both a zirconia and an SSC option. And then, just be confident.
These are tools I made for my treatment office managers and office managers so they can ask: Is this tooth visible? When is this tooth going to exfoliate? Because you know the line: it’s a baby tooth that’s going to fall out anyway. It will eventually, in seven years. “If you’re okay with silver for seven years, I’m okay with that too. I just want you to know it’s going to be there for seven years.” Make tools like this so your team knows how to communicate: “She has a crown on C. This is where C is. Is it visible? Yes, it’s visible when she smiles.”
So calibrate your team to share a unified message about what you’re doing. For us, we’re not offering zirconia just because it’s a product that brings in more revenue. It’s because I truly believe in it. I stand behind it. It allows me to live my philosophy and my standards, and I’m really proud of the care we can deliver to the kids in our community.
[00:59:36] Marketing your zirconia crowns
Once you start incorporating this, your patients have to know you do it. So market yourself: market that this is a product and a service you offer. You spend a lot of time, especially if you go to Sprig U, and a lot of money; you bought this product. It’s something your patients should know about. So, just a little video.
Video (played in the presentation): When it comes to Sprig zirconia white crowns, two things matter most: who places them and what product they use. At Kids Tooth Team, we never use off-brand or off-label white zirconia crowns. Some of those chip, break or just look really unnatural. Our Sprig zirconia crowns are the highest grade, most biocompatible zirconia crowns in the industry, designed to be strong, healthy and beautiful. Every one of our doctors is Sprig zirconia certified and highly trained in placing them. The truth is, most pediatric dentists learn […]. So when you choose a practice to place zirconia crowns on your child, make sure you choose the experts who do it right the first time and use Sprig crowns.
[01:00:34] Sprig University and wrap-up
Not to throw anyone else under the bus, but you have to promote yourself and this incredible service and product you’re offering. I hope you feel more confident presenting zirconias, knowing it’s an incredible product to use in your practice.
If you clinically aren’t feeling quite confident yet, the next slide is for Sprig University. I hope you’ll join us. Look at the instructor-to-student ratio: I know some of the other workshops have 80 students and a couple of instructors. Ours are really small, and that’s by intention. We want to dedicate hands-on time to you really learning the technique and feeling confident clinically. So we’d love to have you at any of our Sprig Universities.
Just think through why you’re offering what you offer. We’re really trying to avoid supervised neglect and the approval addiction all of us suffer from, so we know we’re recommending the things that are absolutely best for our kids and our community.
I really appreciate you all spending an hour after work. I know everyone’s pooped, and you took time away from your families and from relaxing to be here, so we really appreciate you attending. I hope you can come to one of our Sprig Us. I’m teaching the one in Naples next year; I think it would be a perfect excuse to go to Sydney. You should check that one out too. Scan the QR code to learn more. You’ll also get a follow-up email with some promo codes and more information on our Sprig Universities. And like I said, I’m happy to be a resource to you in any way I can.
I’m sorry I ran a little over, but I’m happy to answer your questions. Let me see if I can open up the question box.
[01:02:10] Q&A
The first question here is: do I do them awake if behavior is poor?
Like we talked about before, I assess the sedation modality first, before I talk about what options we’ll offer. If this is a kiddo with really challenging behavior and, for whatever reason, mom is opposed to oral sedation or anesthesia, then I’m going to pivot. Like I said, I do a lot of Hall crowns in my practice. “Hey mom, if you’re completely opposed to any sedation modality I’m offering, our choices here change. We’re going to do a silver crown: I don’t have to get your child numb, I don’t have to prep the tooth, and placing it takes two seconds. That’s an option. But if your priority is a more durable, more aesthetic, beautiful product, there are other ways we’ll have to do this.”
Especially when you’re first starting out, pick cases with kids who have good behavior to do awake. I do zirconias on awake kids all the time, but if they’re kicking around and thrashing, that’s probably not your first zirconia case. So behavior and cooperation definitely factor into what you offer those families. But again, I’m not avoiding definitive treatment. A Hall crown has a 95 to 99% success rate. I’m comfortable doing that because I’m treating the disease and restoring form and function. If it’s past the DEJ, I don’t do SDF in my offices.
So have these dedicated philosophies. Say cooperation isn’t great. I’m going in hoping I can do a zirconia, but mom is well aware ahead of time: “Hey mom, I know our goal is to get a white crown on here. If at any point it’s not safe for me to continue, or they’re not having a good experience, we’ll have to pivot and do a silver crown. I want to make sure you’re okay with that.” If mom isn’t okay with silver, I’m not even going to start the procedure. I don’t feel comfortable moving forward, because I want you to have the results you want. So really the only way I can accomplish this safely […]
Let’s see, I’ve got more questions. Do you tell families you can’t guarantee you can place one? Okay, the same question.
That’s another thing I meant to mention: I warranty all my zirconias in my practice. I didn’t at the beginning, but we do a lot of studies in our office on our failure rates. I like knowing when things fail. In fact, in one of my Sprig webinars, I shared all of my zirconia failures, which isn’t a lot: maybe 10 failures out of 1,600 zirconia crowns. My failure rate for zirconias is way lower than for SSCs, which come off or get worn through way faster.
Once we realized how low the failure rate in our office was, I started telling parents I warranty it. If something happens, just come back, and I’ll fix and replace it. “I want you to feel good about this. I know you’re spending money on this product, but it’s an investment, and it’s something I know is so good and can stand behind. If anything happens, just come in and we’ll take care of you.” I think that makes parents feel really good about choosing this product and investing the money in it, because we have such a low failure rate in our offices.
[01:05:22] Closing
No other questions, so I’ll let you head out. Thank you so much for being here. My email again is… let me see if I can get back to that. Okay, never mind, my email is gone. But if you need anything, I’m happy to be a resource, and I hope you have a wonderful night. Jennifer, if you need to say anything else before everyone leaves…
Host: Thank you, Dr. Alex. On behalf of Sprig, we thank everybody for joining tonight. A huge thank you to Dr. Alex Otto for sharing actionable strategies, especially around framing benefits for parents and addressing common objections. We hope Dr. Alex’s perspective on communicating the value of zirconia crowns gave you practical language and tools you can use confidently in consults. For tuning in, we have a special offer of 20% off your order with us. Please watch for an email with the survey questions, promo details and how to get your CE credits for tonight’s webinar. Have a wonderful evening, and we look forward to seeing you at our next sessions, coming soon. Have a lovely evening, everyone. Good night.
Thank you, everyone. Good night.
