I’m about to give you one of the most powerful pieces of advice that can immediately improve your productivity, reduce your stress, and elevate the quality of your care. It’s this:
Stop doing big fillings.
That’s it. Stop doing heroic, multi-surface, wrap-around composite restorations that are holding a tooth together by a thread. Those massive fillings are costing you more than you think—in chair time, post-op complications, patient complaints, and ultimately, your profitability and reputation.
This is about understanding why these procedures are a losing proposition for everyone involved. It’s time to establish clear diagnostic red lines, present treatment with confidence, and build a practice that is more predictable, more profitable, and far more enjoyable.
Just Because You CAN, Doesn’t Mean You SHOULD
The core of this issue is simple. With modern materials, we can technically restore half a tooth with composite. We can spend an hour meticulously sculpting something that looks okay in the moment. But are we truly serving the patient in the long run?
This is where you must develop a personal diagnostic philosophy. My approach is straightforward: I will not perform any restorative dentistry unless I am confident it will last at least 10 years.
If I look at a tooth with undermined cusps, a cavity that’s wider than it is tall, or a massive failing restoration, and I can’t honestly tell myself it has a great chance of lasting a decade, then a filling is not the right treatment.
When a dentist performs a “heroic” filling on a tooth that structurally requires a crown, it is the dentist who gets burned in the end. That massive filling will fail. A cusp will fracture, a margin will break down, or the whole tooth will crack. Now the patient has lost the money they spent on the filling and must pay even more to fix a bigger problem.
Remember the purpose of our materials. Fillings are for filling small holes. Crowns and onlays are for restoring structural integrity. Stop trying to make a filling do a job it was never engineered for.
Watch the full breakdown of why this one change is so critical.
What To Do When The Patient Says “I Can’t Afford a Crown”
This is the moment of truth. You correctly diagnose a crown, present it to the patient, and they immediately push back on the cost. In that moment of pressure, many of us feel guilty and backtrack, agreeing to do the big, compromised filling we know we shouldn’t.
This is a trap. If a patient cannot afford the right treatment, it does not obligate you to do the wrong treatment.
Some dentists then jump to another false conclusion: “Well, I guess we have to pull the tooth.” This is also often clinically incorrect.
From now on, I want you to see this situation as very simple. Here is your new protocol:
If a tooth needs a crown and the patient says they cannot afford it, you do nothing.
You heard me right. You don’t do the wrong treatment. You don’t extract a restorable tooth. You calmly and professionally explain the situation:
“Mrs. Jones, based on the weakened state of your tooth, the only treatment I can confidently recommend that will last you a long time is a crown. I completely understand that the cost is a concern right now. A filling, in this case, would be very likely to fail quickly and could lead to the tooth breaking, putting you in a worse situation. So, the best option is to simply monitor the tooth for now. We can help you keep it clean, and perhaps in six months or a year, we can revisit placing the crown then.”
This isn’t heartless; it’s the most ethical and professional option. It protects the patient from spending money on a treatment destined to fail, and it protects you from the inevitable complaint when it does.
Because when that massive filling fractures the tooth a year later, the patient will not thank you for trying to save them money. They will blame you for the failure. It is a no-win situation for the dentist.
Your Action Plan to Stop Compromising
- Define Your Diagnostic Red Lines. Establish your own clear, non-negotiable criteria for when a tooth requires a crown. Is it when the prep is more than half the intercuspal width? When a functional cusp is undermined? Write it down.
- Stick to Them. No Exceptions. Do not let anyone—not the patient, not your own guilt—make you compromise your clinical judgment.
- Train Your Team. Share your red lines with your hygienists and assistants. They can help reinforce your diagnosis and hold you accountable to the high standards you’ve set for your practice.
By adopting this philosophy, your dentistry will become more predictable, your profits will increase, and you will sleep better at night knowing you are standing by your professional judgment every single time.
