Table of Contents

Esthetics
Restorative

Inside Dentistry

May 2006, Volume 2, Issue 4
Published by AEGIS Communications

The Smile Makeover Craze: What It Means to You and Your Patients

Allison M. DiMatteo, BA, MPS

Smiles. Thanks to a host of interrelated factors—including mass marketing efforts on the part of product manufacturers and dentists, television shows, and a society enraptured over consumerism and lifestyle upgrades—the value of a picture perfect smile has reached hot-commodity proportions. As a result, dentistry is experiencing tremendous growth, profits, and attention because patients are seeking out, requesting, and undergoing cosmetic dental procedures more than ever before.

“Cosmetic dentistry has been estimated to have increased by about 30% across North America as a result of the increased patient awareness generated by shows like Extreme Makeover,” notes William Dorfman, DDS, FAACD, the Los Angeles-based dentist who performs the smile makeovers seen on the show. “People see that the process is life-changing, and the show has really taken a lot of the mystery out of cosmetic dental treatments.”

In the past 5 years, the esthetic/cosmetic services provided by dentists grew an average of 12.5%, with some experiencing close to a 40% increase.a In fact, 40% of the respondents who participated in a recent 9,000-practice study in the United States reported growth of over 15% in the number of cosmetic dental procedures they perform.

These weren’t practices in upscale Manhattan, Beverly Hills, or South Beach locations, either. Rather, 56.6% of the cosmetic dental practices responding were found in suburban US communities,a suggesting that the smile makeover craze has truly gone mainstream.

In terms of revenue, the craze for a brighter, better, and more beautiful smile has translated into production of more than $700,000 each year, with an average of $661,000 annually, for 48.3% of the practices studied. Additionally, 33% of responding practices reported having more than 2,000 active patients who spend—on average—more than $400 per visit.a

But it’s not just dentists who are reaping the rewards. “Increased patient awareness of what dentists can do has helped the laboratory business overall,” observes Jim Shuck, vice president of sales and marketing for Glidewell Laboratories. “The bulk of Glidewell’s work is still single all-ceramic units and mixed bridgework, but we are seeing more veneer cases.”

Some say the smile makeover craze is being fueled by “the young and the beautiful” and the baby boomers eager to maintain a more competitive edge by flaunting a more youthful appearance. However, the typical cosmetic dental patient—at least 70.2% of those inquiring about cosmetic dentistry—are patients in the workforce or stay-at-home parents between the ages of 31 and 50 years old who want to look and feel better for themselves and, by association, their jobs and personal lives.a

With the smile makeover craze has come simultaneous critical and complimentary attention to the procedures used to create the well-publicized dramatic changes that today’s dentistry makes possible. On the one hand, removal of otherwise disease-free tooth structure in order to place cosmetic restorations and achieve the patient’s ideal look may be considered contrary to nonmaleficence (ie, do no harm).b On the other hand, evidence supports the fact that today’s cosmetic dental treatments are durable and long-lasting, particularly when combined with accurate diagnosis and prognosis.c

Regardless, the desire for a dynamite smile is driving patients to dentists. Dentists therefore have the opportunity to provide not only the treatments patients want, but possibly also those that they need. Whitening remains the most-requested cosmetic dental service, but 25.1% of the procedures performed in a cosmetic dental practice are classified as preventive, thereby underscoring the important role that cosmetic dentistry can play in overall oral health.a

“The increased awareness of cosmetic dentistry opens the door to explain that having a good-looking smile goes hand-in-hand with good oral hygiene and maintenance,” Dorfman says. “When whitening became popular, it didn’t just increase whitening procedures, but also cleanings and preventive treatments, so there’s been a halo effect that really encompasses all of dentistry. Whether they liked it or not, people were ending up with better oral care and better maintenance.”

Here’s the Inside look at what’s really driving the patients who are driving the smile makeover craze—from direct-to-consumer marketing to television shows, and from societal pressures to individual psyches. To assist in maximizing an understanding of the person behind the smile, recommendations are provided for conducting consultations in order to better manage patient expectations. And, when there’s more to the smile makeover than meets the eye, important considerations are offered in order to truly educate patients about what is clinically required and realistic.

Feeding the Frenzy

Advertisements in print and on television, the movies, and just about every aspect of visualization around us encourage perfection of attractiveness, notes James Dunn, DDS, a professor of restorative dentistry and clinical research at Loma Linda University School of Dentistry. What’s more, there’s never been another point in time during which people are looking at health issues, their exercise habits, the types of foods they eat, and their overall lifestyle the way they are today, notes Nicholas C. Davis, DDS, MAGD, president of the American Academy of Cosmetic Dentistry (AACD). Put it all together and you’ve got a society ready and willing to pursue those avenues that will help them achieve their ultimate outward appearance, some members of which may feel that they have to undergo cosmetic enhancements just to keep up with everyone else.

Companies that manufacturer smile-enhancing products have capitalized on—if not contributed to—this phenomenon by marketing cosmetic dental products not only to dental professionals, but also directly to consumers. Consumer-driven marketing initiatives acknowledge and answer the general population’s desires for better looks and a healthier lifestyle. Combined with heightened media attention to the possibilities of smile makeovers, they’re leading to increased demands for cosmetic dental products and services—both from dental practices and over-the-counter retailers.

“You combine consumer marketing with the positive publicity of television—and the fact that the people who are your target market have the money to spend on your services—and it’s like you’ve got all of your stars lined up in a row,” says Dorfman, who is also the co-founder of Discus Dental, a worldwide marketer and distributor of clinical and esthetic products for dental professionals and oral care products directly to consumers. “Baby boomers, for example, have more money than they ever had, and they want to look better, live longer, and increase the quality of their lives. This all fits into the scheme of cosmetic dentistry.”

And it fits well into manufacturers’ agendas, also. When Ivoclar Vivadent’s IPS Empress® product was featured in a consumer television commercial aired during an episode of Extreme Makeover, the company’s marketing executives learned that after watching and seeing those spots, patients across the country started asking their dentists about cosmetic dentistry and how they could improve their smiles.

“Dentistry today is patient-centered. Patients are seeking not only esthetic dentistry, but better dentistry,” explains Robert A. Ganley, CEO of Ivoclar Vivadent. “I think the Esthetic Revolution and our efforts to communicate directly with patients have helped to educate them about what is possible not only esthetically, but also comprehensively, in order to maintain natural-looking and healthy teeth.”

While the number of people interested in smile makeovers has increased significantly, Robert Ibsen, DDS, the founder and owner of Den-Mat Corporation, notes that there is also a great number who are unwilling to have a smile makeover because of the morbidity of the process. Some patients don’t like the idea of having their teeth permanently cut or ground down, or of undergoing anesthetic injections. Therefore, when marketing the benefits of its LUMINEERS® pressed ceramic laminate veneers directly to consumers, Den-Mat focuses on the product’s differentiating points, which include patient comfort and convenience (eg, no preparations or injections), as well as esthetic results.

“When patients find out that they can have dramatic changes in their appearance without anesthetic and in usually less time, there is a huge number of patients who were unwilling before who become very willing after. So, the reason we are doing this [marketing directly to consumers] is to let people know what is available and give them a choice,” explains Ibsen. Specifically, Den-Mat advertises LUMINEERS® in mainstream consumer media as the “no shot, no anesthetic, no painful removal of tooth structure” alternative without any negative side effects. “Once people see that, they become very interested.”

Procter & Gamble—a company that has traditionally built its brand names by marketing directly to consumers—has done well as a result of the smile makeover craze. According to Robert Gerlach, DDS, MPH, principal scientist in worldwide clinical investigations for P&G, the company’s whitening business has grown from nothing 5 or 6 years ago in what he calls the “whitening intensives” into a healthy business today.

“When we did release the whitening toothpastes in the 1990s, there was still considerable unmet consumer need, particularly for shorter-term intensive treatments for improving the color of people’s teeth rather quickly,” Gerlach explains. “We felt that we could bring both better technology and more rigorous pharmaceutical-like research to the arena and better meet consumer needs.” Hence, the company introduced the Crest Whitestrips® product.

Who’s Having What Done Where

Of the patients who inquire about cosmetic dentistry, doctors have reported that a staggering 96% of them are female.a This figure is consistent with 2004 statistics regarding cosmetic surgery, which indicate that 87% of all such patients were women.d

“One of the greatest changes as a result of makeover shows is that people see that it is okay to change the physical things about themselves that they don’t like,” Dorfman says. “In the past, it was secretive.”

The top 5 cosmetic surgery procedures in 2004, in descending order, were liposuction, nose reshaping, breast augmentation, eyelid surgery, and facelift.e That year, however, there was an increase in women having lower body lifts of 59%; buttock lifts of 52%; thigh lifts of 45%; upper arm lifts of 40%; and breast lifts of 14%.d For men, there were increases of 368% for upper arm lifts; 268% for lower body lifts; and 43% for thigh lifts.d

The top 5 minimally-invasive cosmetic procedures in 2004, in descending order, were Botox, chemical peel, microdermabrasion, laser hair removal, and sclerotherapy.e From 2000 to 2004, there was an overall increase of 35% in women and 43% in men undergoing minimally invasive procedures.d Interestingly, for men during the same time period, a breakdown of those statistics shows a 250% increase for Botox injections and a 150% increase for microdermabrasion.d

When it comes to transforming a patient’s smile, there are many options available depending upon the clinical situation, the patient’s financial constraints, and his or her cosmetic expectations and concerns regarding longevity of treatments. To foster greater case acceptance, 81.1% of practices that participated in the recent study reported that they emphasize patient education and open communication with patients, in addition to offering third-party financing to help them pay for their new smile.a

The most commonly requested procedure is tooth whitening, but this represents only 6.5% of all procedures performed in the cosmetic dental practice.a Crown and bridge treatments remain the top procedure performed at 24.4% of all procedures, followed closely by direct bonding at 19.4%. Inlays/onlays accounted for 6.9% of procedures, implants 6.7%, and veneers 3.6%. Removable prosthetics represent 7.4% of all procedures performed and, again, the remaining 25.1% of procedures are preventive.a

When US adults were asked in 2004 what they would most like to improve about their smile, the most common response involved whitening and brightening their teeth.f According to Gerlach, tooth whitening is often the first cosmetic procedure, and it is often the start of a long-term relationship between dentists and their patients.

“It’s often the one thing patients want from dentists,” Gerlach says. “They often don’t want therapeutic care or other treatments, but they almost always want white teeth, so whitening is a way for people to get involved in dentistry and have something that they value immediately and tangibly.”

“Not everyone is going to have plastic surgery or diet, but a lot more people are going to be able to get their teeth fixed—even if it’s just bleaching—because shows like Extreme Makeover have certainly put cosmetic dentistry on the map,” notes Anthony Griffin, MD, a plastic surgeon featured on the show and a member of the American Society of Plastic Surgeons. “A lot of people now are getting their teeth whitened or straightened, and they realize how important a smile is.”

There are instances in which smile makeovers are one of two or more cosmetic procedures that a patient may choose to undergo in order to change his or her facial appearance. Notes Frank Spear, DDS, MSD, the editor-in-chief of Advanced Esthetics and Interdisciplinary Dentistry magazine, if a patient is considering any cosmetic surgery, his ideal is to have it occur prior to any dental treatment because any facial procedure (eg, lip procedures, facelifts) significantly changes the amount of tooth display.

“More and more dentists are working with plastic surgeons to create an overall cosmetic look to improve the patient’s facial appearance,” Davis says. “We can no longer practice in a vacuum, just fix the teeth, and leave the rest to other people.”

However, when the smile makeover has been completed first, subsequent cosmetic surgery may seem unnecessary by the patient. Suggests Ibsen, once people have an attractive smile, many would certainly think they look good enough, and there would probably be less demand for the rest of the surgery.

“If you think about it, the smile is 80% of the result,” Ibsen says. “If you get an attractive smile, the rest seems unnecessary.”

Interestingly, in terms of what’s being done and how, there are trends occurring within the realm of cosmetic smile makeovers. According to Davis, within 10 years, all-ceramic restorations—an increasingly popular restorative choice—will overtake those that are metal-supported. Additionally, to realize smile makeovers that encompass all aspects of smile esthetics, clinicians are more closely attending to the gingival tissues in their diagnostic processes when evaluating a smile (ie, whether to raise or lower the gums to create symmetry, as well as treating gum disease). Associated with this is examining the manner in which the teeth complement the face because some treatments may require orthodontics or orthognathic surgery to shift the jaws and create an overall look, Davis explains.

Makeover Motivations

What’s motivating people to enhance their smiles is a combination of factors. People from various age groups are interested in smile makeovers for different reasons based on where they are in their lives. Baby boomers don’t want to let go of their youth, Davis says, so smile makeovers are a way to ensure that they’re not overlooked. Young people, as well as those of all ages still in the business world, believe an attractive smile will give them an edge. Or, consider that people are spending more time pursuing their education, delaying marriage, and are now ready to look for a mate; they now want to look good.

For some people, bleaching, veneers, and other moderate changes are an opportunity to indulge in themselves, explains Eugene Hittelman, EdD, associate professor and psychologist in the department of epidemiology and health promotion at New York University College of Dentistry. The gratification doesn’t necessarily come from the change in the appearance, but rather from giving one’s self a gift, he says. There are some people who have always been self-conscious about their appearance and perhaps always covered their mouths when they talked; for them, having a smile makeover and the opportunities to not be so frightened and feel more comfortable are the motivations.

According to Hittelman, the pursuit of smile makeovers is an attempt by people to respond to defects they perceive in themselves in terms of a comparison and an expectation of what could happen. The psychological effects of a smile makeover or any kind of esthetic restoration, he says, could be positive, negative, or neutral depending on what those expectations are.

“Most of the things that people are concerned with in the real world are actually really minor; others don’t really notice them unless the person really focuses on it,” Hittelman says. “For many people, their image of what a smile makeover could be is the image of whatever movie star they had in mind and, when that happens, they are very often disappointed because that’s not what they experienced.”

Similarly, patients who request treatment because their teeth have become stained or worn, or they have diastemas that they’re uncomfortable with, could also be happy, disappointed, or indifferent depending on their expectations, he notes.

With the exception of when real pathology exists, the average smile makeover is an attempt by patients to feel better about themselves, be found more acceptable, and have more attention paid to them, explains Harry Prosen, MD, MSC, professor emeritus in the department of psychiatry and behavioral medicine at the Medical College of Wisconsin. It’s an attempt to be more beautiful and satisfy needs for love and admiration, as well as increase self-esteem. Prosen doesn’t feel these are needs that can be adequately dealt with by having a smile makeover.

“Very often I think people undergo makeovers of their smile or face in order to deal with what is inside of them,” Prosen says. “The procedure may in some cases be successful and the effects last for a while, but then they wear off and the person is back to feeling about themselves the way they did before the procedure.”

Griffin says that a tip-off that someone isn’t a good candidate for cosmetic procedures is his or her obsession about a particular aspect of their body (eg, their nose) and a true belief that changing it will be what changes their circumstances in their relationships and/or careers. “These are not good motivational factors for somebody undergoing a surgical procedure,” he emphasizes.

Prosen cautions that people who feel that their smile is going to improve their lives and the way they feel about themselves are going to be in for a disappointment because they would not have changed themselves internally. Smile makeovers, he says, need to be accompanied by a psychological makeover and a coming-to-grips with how one feels about oneself that cannot be escaped, even with a better smile.

“When a patient hangs their hopes—their whole lives—around a procedure, that’s usually an indication that they are not a good candidate,” explains Griffin. “Or, at the very least, this should send up a red flag that you should proceed cautiously and interview those patients very, very carefully.”

Part of the interview process when working with cosmetic patients is understanding what they want to do from the beginning, Davis explains. For example, he often asks patients what they expect when he’s finished and what the limitations are that they are going to put on him in terms of giving them what they want.

Griffin says that in his cosmetic surgery practice in Beverly Hills, he typically turns away about one third of potential patients. They either physically don’t have anything that can be improved upon, or psychologically their motivations are wrong or he perceives there are underlying psychological issues that need to be addressed.

“If you have a bad smile, it’s okay to change that and get a beautiful smile that enhances your life,” Dorfman says. “In moderation, many of these cosmetic procedures are beneficial, but some people may need counseling or to get the opinions of people who love them before they make decisions where makeovers are concerned.”

Conclusion

Considerable advances in dental material sciences in recent years have helped to propel the increase in cosmetic dental procedures. As a result of television and other media messages, patients are now aware of the smile makeover possibilities, as well as the real improvements that have taken place in terms of techniques. Their own inherent desires for an attractive smile—coupled with their newfound knowledge—have led patients to inquire about what can be done to satisfy their individual cosmetic requirements.

“Quality esthetic dentistry—and that’s the key—quality dentistry applied esthetically and appropriately—is better dentistry because it delivers what the patient wants,” Ganley emphasizes. “Dentistry’s ultimate goal must be to ensure the delivery of quality solutions to dental problems that satisfy the person behind the smile—the patient.”

Dentists, however, are trained to do dental procedures, not necessarily deal with the personalities of the people behind the teeth, remarks Gerard Kugel, DMD, MS, PhD, associate dean of research at Tufts University School of Dental Medicine. With so many schools of thought out there in terms of how to teach and perform cosmetic dentistry, he says it almost comes down to a personal feeling on the part of the dentist regarding what is appropriate for which patient and under what circumstances.

According to Spear, that could mean that in some cases, orthodontics and bleaching might be best. In others, it could mean that the best treatment is no treatment at all.

A challenge for clinicians in achieving the multifactoral objectives of cosmetic smile makeovers is integrating the psychological, biological/functional, and esthetic considerations that affect the overall long-term outcomes of the treatment and the well-being of patients. Successfully doing so, however, represents an opportunity for clinicians to fulfill not only their patient’s expectations, but also their own—expectations for realizing patient satisfaction, practice profitability, and professional development.

a North American Survey: The State of Cosmetic Dentistry. A Levin Group Study Commissioned by the American Academy of Cosmetic Dentistry. 2005. www.aacd.com/media/releases/pr2005_05_02

b Jones KD Jr. Extreme makeovers. J Am Dent Assoc. 2005 Mar; 136(3):395-7.

c Strassler H, Rose L, Goldstein R. Issues in dentistry: extreme makeovers. Compend Contin Educ Dent. 2005 April;26(4):282-85.

d 2004 Gender Quick Facts, Cosmetic Procedures. American Society of Plastic Surgeons. www.plasticsurgery.org.

e 2004 Quick Facts, Cosmetic and Reconstructive Plastic Surgery Trends. American Society of Plastic Surgeons. www.plasticsurgery.org.

f Cosmetic Dentistry Consumer Stats. American Academy of Cosmetic Dentistry. www.aacd.com/media/stats

SIDEBAR 1

What’s in a Smile?
In 2004, a scientific poll of American adults found that 99.7% of the respondents believe a smile is an important social asset (www.aacd.com/media/stats). Also in that survey, 96% of adults said they believe an attractive smile makes a person more appealing to members of the opposite sex, and 74% felt that an unattractive smile could hurt a person’s chances for career success.

Esthetics
According to Harald Heymann, DDS, MEd, past president of the prestigious American Academy of Esthetic Dentistry, esthetics is subject to wide variations and interpretations. Perceptions vary significantly regarding what is and isn’t esthetic. What the American adult population believes contribute to an unattractive smile—according to the 2004 poll—are discolored, yellow, or stained teeth; missing teeth; crooked teeth; decaying teeth and cavities; gaps and spaces in teeth; and dirty teeth.

“I think one of the difficulties that we face in esthetic dentistry is being careful not to impose our concept of esthetics on patients,” he says. “For example, I like to see a beautiful smile that allows for nice, natural-looking teeth with a color gradient in them and characterizations. But unfortunately nowadays, patients all too often want a snowball white smile, because their perception of a beautiful smile is one that has been created and fostered by the media and Hollywood.”

Positive Impressions
A pleasing smile makes a positive first impression on other people, says Harry Prosen, professor emeritus in the department of psychiatry and behavioral medicine at the Medical College of Wisconsin. Further, it helps establish communication in a relationship.

“If the relationship continues, the other person will eventually get to know the person behind the smile and whether there’s anything there,” he points out.

The 2004 survey also found that what people are most likely to notice first about someone’s smile include straightness; whiteness and color of the teeth; cleanliness of teeth; any missing teeth; the sparkle of the smile; and sincerity of the smile. The latter point is a function of the evolutionary history of facial expressions described by Charles Darwin more than 100 years ago, according to Timothy Bromage, PhD, a professor in the hard tissue research unit in the departments of biomaterials and basic sciences at New York University College of Dentistry.

Sincerity
“The only drudgery for me while watching the Olympic Games this year was seeing the fake smiles from the figure skaters,” Bromage recalls. “The characteristics of a fake smile, caused by contraction of the risorius muscles, compared to one that arises from actual joy, are completely and utterly discerned and fathomed by humans.”

The most memorable moment for Bromage during the pairs figure skating competition was the split second prior to the start of the long program performed by the Chinese pair that eventually won the bronze medal. As they took position with fake smiles, at that instant—just before the music started—Xue Shen relaxed and gave her partner, Hongbo Zhao, a genuine smile. “It was unmistakable,” he says.

Additionally, whether in plain sight or only in ear-shot, the presence or absence of a real smile can be detected. Bromage explains that even by listening to someone, we can tell by subtle intonation if they are smiling or not. The mere contraction of the zygomaticus major muscle, pulling up on the corners of the mouth, changes the shape of the oral cavity and the nature of the sounds produced, he says.

Happiness
But smiles convey so much more. For example, according to the feedback hypothesis, the very act of smiling helps to elicit positive feelings of happiness (ie, activity in the prefrontal cortex), Bromage says. Therefore, the question is begged as to whether or not smile makeovers have a compensatory benefit to one’s self-image that makes up for some baseline unhappiness.

“Many people see through a makeover smile as easily as they can detect a fake one,” Bromage says. “Additionally, exaggerating a smile is far more annoying than exaggerating other bits of human anatomy because the face draws so much of our attention.”

SIDEBAR 2

Managing Patient Expectations
Dental professionals who practice cosmetic restorative dentistry are in the unique position to help create a more positive self-image in patients who are truly dissatisfied with the appearance of their smiles. Therefore, patient expectations—and the impact cosmetic restorative outcomes will have on the patient’s psyche and feelings of well-being—must be taken into consideration when treatment planning his or her case.

Smile makeovers cannot guarantee that a patient will have greater self esteem—meaning, the sense of value they have about themselves. However, patient expectations must also be properly managed to avoid disappointments, and this requires honesty and integrity on the part of the dentist who is providing the care, explains Eugene Hittelman, an associate professor and licensed psychologist at New York University College of Dentistry.

“One of the things I feel very strongly about is giving patients realistic expectations,” says William Dorfman, DDS. “There are patients who come in and want something specific that I just cannot do, and it would be dishonorable for me to tell them that I can do it, knowing that I can’t.”

James Dunn, DDS, a professor at Loma Linda University School of Dentistry, says that managing patient expectations and educating patients about what is realistic, possible, and appropriate encompasses a number of factors. These include complete disclosure and understanding the patient both psychologically and physically. Additionally, it involves the clinician remaining absolutely neutral in their evaluation, as well as when giving patients complete biological disclosure, durability disclosure, and disclosure of the pros and cons of treatment alternatives, he explains.

“Everything that is done is going to have to be redone eventually,” Dunn says. “There is no such thing as absolute permanency in what we do, and this kind of open disclosure is very difficult, especially when the patient is more psychologically interested in the treatment than physically in demand of it.”

The media and marketing messages have done wonders to increase patient awareness of what cosmetic dentistry can do. The downside, Dunn believes, is that many would-be patients don’t realize that some of the procedures are not as easy as they look; they don’t fully understand the long-term care requirements; and they don’t realize there will be future costs. Therefore, Dunn advocates that the practitioner be extremely wise in offering, recommending, and performing cosmetic smile makeover treatments.

The following check-list of activities to manage patient expectations can help.

Listen to the patient.
“Knowing what the patient wants is essential, regardless of how trivial it may appear to the clinician, because cosmetic restorative success is defined by patient satisfaction,” explains Harald Heymann, DDS, MEd, the graduate program director for operative dentistry at the University of North Carolina School of Dentistry. “Therefore, I am going to listen to the patient, hear what they tell me they want and need and, within the framework of providing good, healthy dentistry, do what I can to meet their expectations,” he says. For this reason, thoroughly interviewing the patient is very important.

Perform a complete examination.
Clinical and cosmetic success is dependent upon gaining an understanding of the patient’s oral condition. Only with this understanding can an appropriate treatment plan be developed that addresses any noted concerns. Frank Spear, DDS, who practices in Seattle, Washington, considers the examination more of a data-gathering appointment.

“We are not only dealing with outward esthetic appearance,” explains Heymann. “We are also dealing with the form and function of the teeth, including the patient’s bite, occlusion, and periodontal health.”

Spear obtains a series of photographs of every patient who presents with a desire to do something cosmetically. After the examination and before offering a specific treatment plan, he reviews each photo with the patient and explains what he thinks could be different.

Offer a range of treatment options.
Heymann admits that options may sometimes be limited depending upon the nature of a respective patient’s problem. “Too often, patients are looking for a quick fix, but in my opinion, the quick fix is not always the appropriate fix,” he asserts.

Additionally, Heymann cautions that those in dentistry may too often be too aggressive in their approaches. He advocates presenting the patient first with the most conservative plan that can be developed. At times, he says, this may involve orthodontics followed by simple whitening, reshaping, and/or adding contours using direct composite—none of which alter the structural integrity of the tooth.

Educate the patient about what’s possible and what’s not.
Spear provides patients with a book of photos of patients who’ve already been treated so they can see what potential—otherwise “normal”—results might look like as a result of different types of procedures. Similarly, Dorfman notes that it’s important to do whatever it takes to communicate with and demonstrate to the patient what their potential end result will be.

Additionally, Spear takes patients on what he calls a 4-part tour of their mouth (ie, how the teeth look, the condition of their bite, the status of their teeth, and the condition of their gums and bone). “I walk the patient through all of these different parts,” he says. “Even if they presented thinking that they only needed their anterior teeth done, this process allows me to address any concerns in any of those 4 parts that need to be addressed before any cosmetic work can be done.”

Dunn explains that even in the case of smile makeovers, dentists are still biologists and physicians of the mouth. If there are wear or periodontal issues, patients need to be informed that unless they’re addressed, any kind of smile makeover is subject to early failure.

Explain the process, the benefits, and the consequences.
If the simple solution the patient was hoping for cannot be accomplished, it’s important to emphasize that sometimes a step-wise process and treatment plan is necessary—in a systematic approach—to solve their dental problems and yet achieve the best possible outcomes for them, says Heymann.

Spear says patients need to know that a specific problem exists and how different treatments can benefit them. They also need to be educated about the consequences of not pursuing certain treatments.

“From the patient’s perspective, if they are not aware that they have a problem, and you try and present a treatment for something that they aren’t aware of, it’s like you’re trying to sell a car,” Spear believes. “What motivates people into treatment is knowing that they have a problem that, if left untreated, will get worse, but that if treated, will result in specific benefits.”

Walk away.
Those we spoke to agree: if the patient really insists upon something that isn’t appropriate for them, the best thing you can do for yourself—and the patient—is to not do the case. “When a patient comes to me requesting something that is just not appropriate, I tell them that I won’t do it and why. I always will provide them with an appropriate clinical option, but the decision must finally reside with them,” says Dorfman.

“There is a school of philosophy that suggests that if this is what the patient wants, then this is what we should give them,” explains Gerard Kugel, DMD, MS, PhD, associate dean for research at Tufts University School of Dental Medicine. “With that said, I think ethically it can be a tough call for dentists to do what’s best for the patient, even if it means losing the patient.”

SIDEBAR 3

When Cosmetic Dentistry Becomes Comprehensive & Restorative

Sometimes smile makeovers are completed simply for cosmetic reasons. Sometimes, they’re in response to the need to correct more extensive dental problems: wear, poor occlusal relationships, caries, etc. When the patient who expected an almost immediate change is now faced with more extensive treatment, it’s important for them to understand why it’s necessary and that it’s part of ensuring the long-term success of the smile makeover they’ve requested.

“There’s pressure on the dentist because patients present wanting the quick fix when in most cases, in reality, their condition isn’t something for which we can provide an immediate result and get the best long-term esthetic success,” explains Harald Heymann, DDS, MEd, professor and graduate program director of operative dentistry at the University of North Carolina School of Dentistry.

What’s not seen on the Extreme Makeover show are all of the necessary diagnostic and clinical steps required to ensure the longevity and clinical durability of the cosmetic restorations that are ultimately placed. However, all of the problems that might be contributing to the unattractive smile—malocclusion, periodontal disease, improper bite relationship—are addressed, assures William Dorfman, DDS, FAACD, the show’s cosmetic dentist.

“One of the critiques we receive from dentists is that the show doesn’t elaborate on the care, maintenance, or diagnostic/ preliminary steps that are required for the smile makeovers,” he admits. “I assure you, it’s all happening behind the scenes.”

Maybe an Interdisciplinary Approach Is Needed

To achieve an optimal esthetic result, Heymann notes that clinicians may need to involve other disciplines outside of restorative dentistry. For example, if a patient presents with crooked teeth, orthodontics may be warranted to align the teeth into proper position so that optimal results can be achieved restoratively. Similarly, patients presenting with gummy smiles and short clinical crowns may require referral to a periodontist for crown lengthening in order to improve the width-to-length ratios and help ensure the best long-term results.

“In my opinion, what is best for the patient is the procedure that is going to result in the least removal of tooth structure and be the most conservative for long-term esthetic success,” Heymann believes.

Motivate the Patient

According to Frank Spear, DDS, founder of the Seattle Institute for Advanced Dental Education, the only reason anybody ever chooses periodontal surgery, orthodontics, or any other treatment that they weren’t originally planning for is because there will ultimately be a benefit that they want. Until patients know what those benefits are, they won’t accept a more comprehensive treatment.

Spear does acknowledge that there may be instances when certain types of procedures—such as periodontal surgery—are necessary, but that patients lack the motivation to undergo the procedure because they look at the hopeless appearance of their teeth and think, “what’s the point?” That’s when temporarily changing the cosmetic appearance of a patient’s smile may motivate him or her to undergo the entire recommended treatment plan.

“It’s a double-edged sword,” Spear admits. “As a clinician, you don’t want to do work on the anterior teeth and make them look great and finish them, leaving periodontal disease or occlusal problems. But, there are times it may be necessary to do something on an interim basis to make the patient look and feel better so they have the motivation to proceed.”

SIDEBAR 4

What it Means to Be a Cosmetic Dentist

There’s a stigma that’s placed on cosmetic dentistry—that it only makes teeth look nice but has nothing to do with function or maintaining the health of a person’s mouth. Bleaching makes teeth lighter and is purely a cosmetic procedure, having no other value than making the teeth nice and white. Placing veneers on teeth could also make them look nice. But when the veneer procedure is completed in order to re-create the original anatomy that was lost due to wear and reestablish the normal protective functions of the cuspids in their occlusion, then the cosmetic procedure has become clinically and functionally restorative.

“It is very difficult to draw a line between cosmetic procedures and functional procedures,” explains Nicholas Davis, the president of the American Academy of Cosmetic Dentistry (AACD). “We feel that there are components of both in all cases, but clinicians shouldn’t violate basic principles of oral health purely for esthetic purposes.”

According to Richard Simonsen, DDS, MS, a board member of the American Academy of Esthetic Dentistry (AAED), most patients require some form of interdisciplinary care, which is an important aspect of cosmetic—or esthetic—dentistry. For this reason, some of the AAED’s 125 by-invitation-only members are specialists in areas other than restorative dentistry, such as periodontics or orthodontics. Those invited to join must undergo a stringent review process that includes a graded and rated presentation and a variety of other evaluative systems in order to ensure that they are highly qualified.

“Just because a patient is requesting a cosmetic or esthetic alternative does not mean that one should overlook the periodontal, functional, or orthodontic aspects,” Simonsen notes. “One cannot simply jump in and say that 10 veneers or 20 crowns are needed and go ahead and do them without thinking about the impact this has on all of the other aspects of oral health.”

Currently there is no specialty designation in cosmetic dentistry, Davis says. Consequently, cosmetic results can vary widely. It’s not uncommon for seasoned professionals to take numerous courses in cosmetic dentistry and regularly perform a multitude of cosmetic procedures while, at the other end of the spectrum, newcomers advertise themselves as “cosmetic dentists.”

Simonsen says that given the fact that the American Dental Association (ADA) does not have a specialty classification for cosmetic dentistry, he doesn’t necessarily agree that anyone can call themselves a cosmetic dentist. Doing so probably stretches beyond the ADA’s principles and ethics guidelines, he says.

“Right now, what concerns me about the topic of cosmetics in dentistry is that what is considered to be a pleasing and beautiful smile can vary dramatically from patient to patient,” says Frank Spear, DDS, MSD, the founder and director of the Seattle Institute for Advanced Dental Education and past president of the AAED. “What’s starting to happen is that a lot of professionals who want to be ‘cosmetic’ dentists try to follow a formula by which they always use the same size central incisors, or they use the golden proportions to determine the width of teeth. The truth is that natural teeth and natural beauty have imperfections in them.”

Education and discipline are therefore key to successful cosmetic dentistry. Being a cosmetic dentist requires a thorough knowledge of everything that is possible—and under what circumstances. Additionally, Spear notes, it requires reflective thinking about what is nice looking and what isn’t, and what would look good in a particular patient’s face, rather than trying to make cosmetic smile makeovers a rigid science.

“We all know that if you study and are dedicated to supplementing your learning, you can improve your knowledge and skills,” Davis says. “Because there can be wide variations in the level of quality produced by clinicians, the AACD offers an accreditation process which tests and measures those skills.”

Candidates are required to successfully complete and photo-document a specific number of designated cases which are graded in the blind by calibrated examiners. Candidates must also pass a written and oral examination. Unfortunately, states do not recognize the AACD credential because the ADA does not recognize cosmetic dentistry as a specialty.

“Our position is that we are very concerned about the public health and assuring that patients are getting the care and treatments that they expect to receive from cosmetic dentists,” Davis says. Therefore, the AACD is working closely with the Academy of General Dentistry and the American Academy of Implant Dentistry to do all it can to protect and promote the other credentials that are offered and support public health.

Davis suggests that states could require dentists to take a specific number of continuing education courses specifically in cosmetic dentistry in order to be able to advertise as a cosmetic dentist. “I think dental schools would like that, as well as all organizations that provide cosmetic dentistry education,” Davis believes. “It is basically to protect the public.”

Davis and others we spoke to encourage those interested in undertaking more cosmetic cases to participate in continuing education courses—either at universities, private dental institutes, or annual professional meetings such as the AACD or the Esthetic and Restorative Update, an intensive 2-day continuing education offering sponsored annually by the AAED (www.estheticacademy.org)—in order to improve their skills and enhance their knowledge.

“If clinicians wanted to get special skills and perhaps limit their practice to esthetic dentistry, there are places they should go and places where they should not go,” Simonsen said. “My opinion would be that they should attend an institute that focuses on the clinical education (ie, Kois Center, the Seattle Institute for Advanced Dental Education, Pankey Institute), rather than how to market dentistry.”

This year’s Esthetic and Restorative Update was held March 31 through April 1 in Dallas, Texas, and emphasized evidence-based continuing education open to all dental professionals, with distinguished speakers whose participation was voluntary and without honorarium; the 2007 meeting will take place in Seattle, Washington, March 30 and 31.

The 2006 AACD meeting takes place May 1620 in San Diego, California.

SIDEBAR 5

The Inside Look FROM...

Each issue, the publishers and staff of Inside Dentistry—with input and guidance from our editorial board members—bring to the forefront concerns and trends in the oral health care profession that touch everyone in the industry. What make these in-depth presentations possible are the generous contributions of perspectives and insights that our knowledgeable and well-respected interviewees collectively share with us. For that, we extend our sincere gratitude.

Academia

Timothy Bromage, PhD
Professor, Hard Tissue Research Unit
Departments of Biomaterials & Basic Sciences
New York University College of Dentistry
tim.bromage@nyu.edu

James Dunn, DDS
Professor of Restorative Dentistry & Clinical Research
Loma Linda University School of Dentistry
jdunn@llu.edu

Harald Heymann, DDS, MEd
Professor and Graduate Program Director, Operative Dentistry
University of North Carolina School of Dentistry
harald_heymann@dentistry.unc.edu

Eugene Hittelman, EdD
Associate Professor, Department of Epidemiology & Health Promotion
New York University College of Dentistry
elh1@nyu.edu

Gerard Kugel, DMD, MS, PhD
Associate Dean for Research
Tufts University School of Dental Medicine
gerard.kugel@tufts.edu

Harry Prosen, MD, MSC
Professor Emeritus
Department of Psychiatry & Behavioral Medicine
Medical College of Wisconsin
hprosen@mcw.com

Private Practice

William Dorfman, DDS, FAACD
Private Practice
Los Angeles, CA
Extreme Makeover dentist
billd@discusdental.com

Frank Spear, DDS, MSD
Private Practice
Seattle, WA
Director and Founder
Seattle Institute for Advanced Dental Education
FSpear@seanet.com

Professional Societies

Nicholas C. Davis, DDS, MAGD
President, American Academy of Cosmetic Dentistry
Private Practice
Newport Beach, CA
info@smilesbydavis.com

Anthony Griffin, MD
Private Practice
Beverly Hills, CA
Extreme Makeover cosmetic surgeon
Member, American Society of Plastic Surgeons
agriff@pacbell.net

Richard Simonsen, DDS, MS
Board Member
American Academy of Esthetic Dentistry
rsimonsen@cox.net

Industry

Robert Ganley
Chief Executive Officer
Ivoclar Vivadent, Inc.
Robert.Ganley@ivoclarvivadent.us.com

Robert Gerlach, DDS, MPH
Principal Scientist, Worldwide Clinical Investigations
Procter & Gamble
gerlach.rw@pg.com

Robert Ibsen, DDS
Owner & Founder
Den-Mat Corporation
cnewberry@denmat.com

Jim Shuck
Vice President of Sales & Marketing
Glidewell Laboratories
jshuck@glidewelldental.com