September 2007, Volume 3, Issue 8
Published by AEGIS Communications
Dissecting the Debate Over the Ethics of Esthetic Dentistry
Allison M. DiMatteo, BA, MPS
Today’s dentistry is a multifaceted profession that can both treat painful and debilitating diseases and also transform unsightly smiles that plague and distress patients to the extent that their correction is no longer elective, but necessary. Therein lies one of many arguments in a debate that is simultaneously civilized and raging—depending on where you are and who you’re talking to—about the ethics of esthetic dentistry.
A conversation about the ethics of esthetic dentistry involves context. It encompasses intent. In this decade the conversation requires recognition that esthetic—and often elective—dentistry and necessary dentistry are no longer mutually exclusive. And it requires an acknowledgement and understanding of the fact that today’s patients are different from those who once knew dentistry as only a drill-and-fill profession.
"It boils down to what the patient’s needs, wants, and desires are," explains Ronald E. Goldstein, DDS, clinical professor in the Department of Oral Rehabilitation at the Medical College of Georgia School of Dentistry and a private practitioner in Atlanta, Georgia. "We have to judge what a patient’s needs are, whether they’re more psychological and not necessarily physical needs, such as a decaying tooth or periodontal disease, and we have to measure just how important the need for improved esthetics is."
Thanks to heightened individual self-awareness and media attention, clinicians are now treating and managing patients who present with a host of requests designed to enhance their personal image and self-esteem that perhaps were previously unencountered or ignored in years gone by. In fact, according to John Kois, DMD, MSD, affiliate professor in the graduate restorative program at the University of Washington and a private practitioner in Tacoma and Seattle, Washington, there are some patients for whom esthetics is so important that their clinically "unnecessary" treatment can no longer be classified as elective.
"In the traditional reparative view of dentistry, if a patient said he or she didn’t like their smile, the dentist might take a look and say, ‘Yeah, but your teeth are fine,’" explains Matt Messina, DDS, consumer advisor for the American Dental Association (ADA). "Now we’re entering a realm in which a patient saying, ‘I don’t like how this looks,’ is considered a problem that can be fixed."
Richard Simonsen, DDS, MS, dean of Midwestern University College of Dental Medicine, explains that pretty much all necessary dentistry has an esthetic component. "For example, an extraction has potential esthetic impact—except for third molars, of course, but extraction of a tooth in a visible area is going to have an esthetic component to treatment," he explains.
What’s more, the materials available today for even reparative dental procedures are themselves inherently more natural looking or esthetic. As a result, the defining boundaries for what constitutes esthetic vs necessary dentistry are blurring, confounding along with them the ethics surrounding each.
So, if the profession at large concedes that esthetic dentistry can be necessary dentistry—and visa versa—then what are the ethical issues that clinicians are still grappling with? The well-respected professionals who spoke with Inside Dentistry consider several ethical issues key and worthy of consideration and reflection. We offer them here to stimulate continued thought so that, ultimately: the elevated status that the profession has realized in recent years can continue; patient care—even when elective—can remain appropriate, state-of-the-art, and concurrent with standard and accepted practices; and a greater consciousness of what’s in the long-term best interest of the patient can always remain at the forefront of any ongoing debate.
The Essence of the Debate(s)
There are a number of trouble spots when it comes to the ethics of esthetic dentistry, our interviewees say. What’s more, ethics in dentistry encompasses a range of behavior from the dentist’s standpoint, explains Bruce Small, DMD, an associate professor of restorative dentistry at the University of Medicine and Dentistry of New Jersey and a private practitioner in Lawrenceville, New Jersey. Sometimes what is ethical comes down to a decision by a judge or jury, he says.
Selling Esthetic Dentistry vs Oral Health
When marketing and selling esthetic dentistry out-muscle healthcare as the primary reason for treatment, that’s when clinicians could get into trouble, suggests Simonsen. He says elective treatment is an ethical component of today’s clinical treatment, but the key is for clinicians to secure appropriate informed consent (See What Full Disclosure, Treatment Choices/Plans, and Informed Consent Really Involve, page 56).
Of course, Kois notes that ethical issues are always a concern when elective procedures are contemplated. The inference is that the dentist is more entrepreneurial-driven than healthcare-driven, he says, and that the patient would pay a biological price.
"I certainly understand and support the concepts that promote the most conservative treatment options. In fact, I often say, ‘There is no dentistry better than no dentistry,’" Kois explains. However, he elaborates that questions about the ethics of esthetic treatments can paint a limited view of the full scope of treatment because esthetic dentistry is a bona fide part of what dental professionals do, right along with managing occlusion, for example.
"I believe the ethical concerns stem from the qualities that distinguish professionalism from commercialism, and there are two different fundamental images of dentistry, as Ozar and Sokol describe in Dental Ethics at Chairside: Professional Principles and Practice Applications1," explains Douglas A. Terry, DDS, assistant professor in the department of restorative dentistry and biomaterials at the University of Texas Health Science Center at Houston and a private practitioner in Houston, Texas. "The commercial philosophy has no moral code based on a value system other than money and, thus, many times the patient’s needs and well-being are overlooked for financial gain."
In contrast, Terry says that the professional philosophy has a foundation based upon truth, values, and moral boundaries. The professional healthcare view accepts—individually and collectively—an obligation to "do good" and "do no harm" to the public.
"These ethical principles are not forced upon the professional but are an inherent instinct," Terry says. "It’s like our parents taught us; ethics is knowing right from wrong."
Goldstein elaborates further that he finds that it’s sometimes an ethical dilemma for many dentists who are trained in function, occlusion, and well-fitting "conventional" restorations to suddenly switch over to a patient’s mindset of wanting an attractive porcelain laminate or an all-ceramic crown or inlay/onlay. He says those clinicians know they can get longer life from other restorations, and that’s part of what has contributed to the ethical debate that the profession has faced.
"Dentists must appreciate the very delicate balance between the commercial world and the caring world," Simonsen says. "Clinicians have difficult choices because those in private practice are running a business, and without the business being successful, they’re not going to be able to help their patients. At the same time, the dental profession has a moral obligation to improve the health of our patients and a duty not to injure them while doing so."
Answering the question of whether selling esthetics minimizes the emphasis on oral health is further challenged by the fact that clinicians also have an obligation to treat the whole person. Doing so may not always involve what is traditionally defined as physical or as disease, explains James Dunn, DDS, professor of restorative dentistry and clinical research at Loma Linda University School of Dentistry, who echoes earlier comments.
"These are tough times that we face," Dunn admits. "In a competitive, demand-dentistry world in which patients are requesting specific treatments, the dentist is in a tough spot."
Last year, Inside Dentistry reported that cosmetic dentistry had reached an all-time high value among both mainstream consumers and regular, conscientious dental patients. The trends from last year until now suggest that the growth, profits, and attention that dentistry is experiencing will continue their upward climb.
Sharon Turner, DDS, JD, dean of the University of Kentucky College of Dentistry, admits that media hype and television shows about cosmetic dentistry are influencing the trends that the profession is witnessing. Clinicians and their patients are human, she says, and all are living in a commercial society in which everybody is concerned about how they look.
"But it’s important to remember that the average patient may not realize what the inclusion or exclusion criteria are for the treatments being shown on television," Turner advises. "We certainly can be pushed by our patients to offer the services that they want, but we’re the ones who maintain the professional knowledge about what’s safe, appropriate, and will be maintained long-term—as well as what might do harm rather than good."
Gerard Kugel, DMD, MS, PhD, associate dean for research at Tufts University School of Dental Medicine, expresses a similar view. Clinicians have to look at the patient’s condition and, based on their knowledge and abilities to diagnose, develop a treatment plan that is best for that person, he says. "Sometimes I make a decision to not do a procedure that the patient wants (such as veneers when orthodontics and bleaching are more appropriate) at the risk of losing the patient," Kugel says.
To forge ahead unscathed from an ethical dilemma, Dunn suggests returning to the Hippocratic Oath by which clinicians do no harm. Alternatively, he suggests following the Golden Rule by which they do unto others what they’d have done to themselves.
"Clinicians, as healthcare providers, should treat their patients as human beings, not as a commodity," Terry asserts. "Salesmanship should not supercede clinical judgment and responsibility for the welfare of the patient. Patients should not be given short-term smile designs at the expense of long-term health and well-being."
Imposing One’s Own Esthetic Preferences
However, in the realm of esthetics, there’s a fine line between "doing unto others" and over-zealously imposing one’s own esthetic preferences instead of honoring the patient’s desires. "Success is defined by patient satisfaction," explains Harald Heymann, DDS, MEd, professor and graduate program director of operative dentistry at the University of North Carolina School of Dentistry. "At a time when patients desire more and more ultra-white teeth, I try to guide them to what teeth do normally look like and advise them of what I think would look good for them based on their complexion, facial structures, etc. However, ultimately, we do have to listen to our patients and hear what it is that they are looking for if we want to ensure patient satisfaction, even if it is not entirely consistent with our own perception of esthetics."
Right of Conscience
And if you’ve heard what the patient is looking for and understand what he or she wants—but you don’t feel that you can or should do what the patient is asking—how do you proceed? Does a patient have a right to force a dentist to do something against his or her conscience?
"It’s about a dentist’s right of conscience," says Van Haywood, DMD, professor and director of dental continuing education in the department of oral rehabilitation at the Medical College of Georgia School of Dentistry. "The responsibility of the professional is to do what’s best for the patient at least physically as well as emotionally. So, just because the patient wants it does not mean the dentist can or should do it."
Haywood elaborates that from a legal standpoint, a patient cannot agree to or accept malpractice of medicine or dentistry. Therefore, the dentist always has the obligation to do—or not do—what they think is best for the patient, he says.
Over-Treatment and Under-Explanation
And what is considered best for the patient in terms of the extent of treatment (ie, technique) and the materials used might also fall under ethical scrutiny (See Considering Material Selection & Technique Application, page 60). Some have suggested that there are ethical issues with over-treatment and the under-explanation of procedures and alternatives. Options like orthodontics that represent good, conservative treatment modalities aren’t explained as much, observes Haywood. There needs to be more interaction between the patient and the dentist during discussions about different options, the risks involved with the procedures, and their longevity and potential sequelae for retreatment, he says.
Kois explains that if the overall treatment is diagnostically driven based on the patient’s concerns, periodontal health, tooth structure, occlusal health, and esthetic appearance, then a more significant amount of treatment might be necessary to satisfy the requirements in all of those areas. All of those components constitute parts of what is necessary to manage the whole system that dentists must care for, he says.
"As a profession, trying to determine how much dentistry should be accomplished has been difficult," admits Kois. "Too much of treatment is not based on quantifiable data, and it’s not easy to establish judgment protocols that are standardized."
As Goldstein sees it, dentists are obligated to present each and every patient with the ideal treatment plan that’s been developed based upon their clinical, functional, and esthetic needs. That plan, he says, would involve everything necessary to achieve the patient’s and the dentist’s objectives, even if there are recommendations that the clinician knows the patient will be opposed to. Then, clinicians can give a "modified" version of the plan depending upon what the patient can afford and/or is willing to undergo.
"I’ve had many patients who come in and tell me that they’ve been to other dentists who’ve told them that they’ll need orthodontics, but they’re not willing to have braces, so I shouldn’t waste my time talking to them about orthodontics," Goldstein admits. "Still, if after examining the patient I find that there’s an orthodontic component needed, whether the patient wants it or not, I feel I am obligated to consult with my orthodontist/ periodontist partner, Dr. Maurice Salama, to show the patient the ideal way of doing their case with orthodontics. The fascinating part is that many patients then change their minds and accept either the ideal or even a compromised plan that we suggest, which may include an orthodontic component created by Dr. Salama."
Removing Acceptable But Unesthetic Restorations
Another issue with ethical implications is the removal of acceptable but unesthetic pre-existing restorations in a non-allergic patient. "Every time you remove an old filling, the preparation gets bigger and the tooth gets weaker," Haywood explains. "So, if you’re taking a functional filling out and putting in one that’s bigger, by default it’s going to have a shorter life span."
Of course, if the pre-existing restoration in question is amalgam, even more delicacy is required. Small notes that if a patient has an amalgam restoration that is not decaying, he doesn’t feel it should be taken out unless there is some biological reason that it should be. In fact, it is a violation of the ADA Principles of Ethics and Code of professional Conduct for a clinician to recommend that a functional and non-defective amalgam restoration in a non-allergic patient be replaced for the alleged purpose of removing toxic substances from the body.2
According to Kugel, there is no hard scientific evidence that there is any danger to having an amalgam restoration. Additionally, an increasing number of articles published by such organizations as the ADA, the National Institute of Dental and Craniofacial Research, and the American Medical Association report that no problems have been seen when amalgam fillings are placed, he says.3-7
"If a patient requests that a functional and non-defective amalgam restoration be replaced and they still want it replaced after the clinician has fully disclosed and explained all of the potential consequences to alternative restorations, then it is up to the discretion of the dentist whether or not to do that," asserts Haywood. "The challenge is making sure the patient is fully informed and that what’s being done is good dentistry, because taking out restorations that don’t need to be taken out is right on the border."
Kugel says the replacement of a defective amalgam restoration is a different story, but patients still need to be informed of all of their options, which include replacement with amalgam. "I tell patients that I can place a tooth-colored filling or another amalgam filling," he says. "Some people think that’s controversial, but there is no evidence of any danger, and I tell patients that."
Goldstein says that the replacement of a filling or restoration can ethically be completed when it’s defective, and that can be established when there’s evidence to support the dentist’s observation. Clinicians have the ability today to determine whether or not restorations are defective by using such technologies as intraoral cameras, which enable enlarged views of restorations by 10X to 20X magnification, he says. "The beauty of this diagnostic technique is that the patient can see the defect as I do," Goldstein notes.
Negative Sequelae from Elective Procedures
Another caveat of removing amalgam restorations—defective or not, says Kugel, is ensuring that proper isolation (eg, rubber dam) is used. "I find it ironic that the dentists who may be encouraging patients to have amalgam fillings removed are the same dentists who won’t use a rubber dam," he says. "And if they’re going to be placing composite fillings, they should ensure that they’re correctly following the proper adhesive and placement protocol."
Among the consequences that clinicians could encounter when performing unnecessary or elective dentistry may be negative sequelae following elective treatments—such as teeth requiring root canal therapy, periodontal care, or a restoration that falls off, among others, Small explains. Therefore, he says ethics is all about giving the patient the longest-lasting material that’s going to be the most minimally invasive.
"Each time you place another restoration, you remove more and more tooth structure, so you need to be as conservative as possible," Haywood says. "The hardest substance in the body is enamel, and it’s meant to last a lifetime. Once you start removing enamel from teeth, you begin to shorten the functional life of the patient’s teeth."
In developing plans for esthetic treatments, Kois says clinicians could have as their goal to change the risk in the treatment to one of a failure in the restoration, not a failure in the tooth.
"If the worst that happens is a chipped piece of porcelain, that’s certainly not as catastrophic as a tooth that breaks off at the gumline and now has to be lost," Kois emphasizes. "If the patient wants esthetic procedures done that will really compromise the tooth, that’s the point at which I would draw the line. There always has to be a line in the sand where we say, ‘I’m not going to do that.’"
QUICK-FIX ESTHETIC TREATMENT VS COMPREHENSIVE TREATMENT PLANS
Perhaps that’s why other arguments center around the quick-fix esthetic treatment vs the comprehensive treatment plan. With the quick-fix mentality, the most apparent esthetic problem is addressed (eg, law of the apparent) first, leaving other parts of the system to become more apparent, and they’re not necessarily attractive, Kois explains. "If a patient doesn’t have an overall comprehensive care plan for all things that could be affected once changes start to be made, many times the quick-fix approach doesn’t adequately satisfy their needs," he says.
For example, in this Catch-22 situation, Goldstein imagines a clinician performing an esthetic smile transformation for which laminates will be placed. The patient has some pre-existing but good and well-functioning amalgam restorations on the lower teeth that show when they laugh or talk. Or, the amalgams are on the top teeth in the bicuspid area but they show from the front and, even if a laminate were placed, the discoloration would show through, he envisions.
"I think you are ethically bound to tell the patient that they have amalgam fillings in those places and that, in the case of the bicuspids, they may not provide the same retention and, therefore, it would be better to replace the amalgam with a composite restoration to facilitate bonding, or if the amalgam is quite large and showing from the labial, to even suggest a full crown or laminate/onlay," Goldstein explains. "Or in the case of the lower teeth, you want to avoid a patient being unhappy with a new smile because they can still see dark fillings when they open their mouth."
It’s important to emphasize for the patient that the amalgam restorations are in perfect condition and will provide longer life than other alternatives, he says. If clinicians understand what the patient wants—in this case, a smile transformation—then a comprehensive treatment plan would address all of their needs and wants from the beginning, Goldstein believes.
Among the restorative modalities that could be used for quick-fix, conservative, and comprehensive dentistry, the options are not mutually exclusive. Once such esthetic criteria as the shade of the teeth have been determined, Heymann says it is then the clinician’s primary role as a healthcare provider to ensure that restorations demonstrate proper function and promote good gingival health. Clinicians should include in their discussion of alternatives—and maybe even emphasize—the most conservative option possible for that patient first, "because first and foremost, there’s nothing that we can place on or in teeth that’s as good as what Mother Nature put there to begin with."
When it’s not possible to meet the patient’s esthetic demands through conservative approaches, then more comprehensive or possibly invasive treatments can be discussed. In many cases, the best option involves longer periods of time, Heymann says, unlike the manner in which so many smile makeovers are depicted in television shows (ie, as if they can be attained overnight). The ideal treatment may involve an interdisciplinary approach and specialty therapies like orthodontics or periodontics in order to achieve the best long-term, most stable outcome and esthetic result for the patient, he explains.
In many ways the "quick-fix approach" represents a compromise perhaps because the teeth weren’t where they needed to be orthodontically, for example. Trying to put the teeth where they need to be restoratively has its limitations and can have negative implications for soft tissue health, Heymann says.
"Clinicians cannot just give a patient a plan that is going to satisfy only their esthetic requirements," emphasizes Small. "The plan should account for incisal guidance, canine guidance, and noninterference of the posteriors. They should include both function and esthetics from the beginning, or else they’ll experience failures."
REVISITING WHAT’S ELECTIVE AND WHAT’S NECESSARY
The overwhelmingly powerful role that physical appearance plays in patients’ lives places esthetic dentistry increasingly in the category of necessary dentistry, even though the two are no longer mutually exclusive. However, as mentioned earlier, many dental procedures may contain an esthetic component or an aspect that impacts esthetics.
Haywood notes that presenting patients with treatment options that will result in a more esthetic smile does not necessarily mean that the "selling of esthetic dentistry" is taking place. After all, properly aligned teeth (ie, that result from orthodontic positioning) and properly-cared-for teeth (ie, from regular hygiene and soft tissue care) are very esthetic, he says, and most likely deliver proper function and phonetics.
According to Goldstein, "it’s not possible in this day and age to say that because something fits well and we, as dentists, judge it as a perfect restoration, that the patient should see it that way. When there are other factors to be considered—such as the patient’s psychological wants—I think we are ethically bound to understand that patient’s needs and act on them with our ability."
According to Kois, where and how to draw the line regarding what procedures to do and not to do varies by patient and clinical situation. Therefore, judgment of another practitioner can’t be based on something that’s seen in a magazine, he notes.
"Ultimately, patients do have a say in what’s to be done," Kois says. "The dentist should have full confidence that whatever they’re going to do will be provided for the patient with the longevity that everyone expects."
Kugel notes that clinicians should remember that the patient and what’s best for him or her should always come first, not what’s in the best interest of the dentist or the practice. And what’s best for the patient involves function, long-term stability, and quality of life, he continues.
"These ethical issues are not about elective vs. mandatory treatment, but about moral behavior," notes Terry. "I believe it can best be described by what Dr. John Buhler, who was dean of Emory University School of Dentistry in Atlanta, Georgia, said to the freshman class over 50 years ago: ‘We can give you skills and knowledge, but in regards to ethics, you will leave this university with what you came with.’"
Fortunately, dental professionals today are in a position to do the right thing—and do it well. Today’s technologies enable them to treat disease and produce esthetic changes, Dunn suggests. Practitioners can use materials that look, feel, and function like natural teeth, and this may be where the excitement of the profession toward the future should be. One day, all dentistry will be "esthetic" dentistry.
"What dental product manufacturers introduce in the future will be couched in providing clinicians with the ability to replace missing tooth structure in a way that it appears, functions, and lasts as if it were natural tooth structure or, in some cases, better than natural teeth," believes Messina. "That’s really the joy and fun of the future of dentistry—that we can put people’s teeth back together and make them as good as they were before, if not better."
What Full Disclosure, Treatment Choices/Plans, and Informed Consent Really Involve
Individual patients should actually be in charge of their own care. They should make decisions based on logical and ethical information provided to them by the practitioner about their current condition and suggested treatments and their effects, explains James Dunn, DDS. Therefore, to accomplish such a task, patients need complete biological, durability, and benefits/limitations disclosure, he says.
Thorough education and information enables patients to work with their clinician to determine the best approach to suit their needs, explains John Kois, DMD, MSD. Very often the knowledge they obtain may allow them to move away from what could have been a quick-fix, he elaborates, to something requiring longer-term treatment but that has a much more predictable outcome.
Full disclosure or informed consent consists of several aspects of clinical procedure, communication, and education that must take place between the dentist and the patient in order to ensure that the patient’s care is the primary concern. Additionally, before consent should be accepted, practitioners should assess whether or not patients fully understand what’s been presented to them and/or are capable of making a treatment decision in their own best interests, explains Richard Simonsen, DDS, MS.
"Treatment planning should be based upon a progressive treatment modality that begins with the most conservative option and progresses as needed to a more invasive option," notes Douglas A. Terry, DDS. "Additionally, patients should be informed not only by ‘words on paper’ from a standard legal form that protects the clinician, but by detailed descriptions of procedures so that patients can understand the long-term biomechanical risks associated with more invasive procedures, and thus make educated decisions for their oral health. Many times the best dentistry is no dentistry."
"What I’m most concerned about as a profession is preventing a patient coming to us after treatment who says they wish they’d never had it done, or who says they didn’t know they could have undergone something more conservative," says Kois. "I’m not talking about them being disappointed with a color in the final restorative outcome. I’m talking about preventing the bitterness and unhappiness patients can experience after treatment, something that could be different if they were educated properly and clearly understood the choices they had initially."
Here, we outline what our interviewees suggest are involved with complete disclosure, informed consent, and presenting treatment choices and plans.
Nature of the Patient’s Condition
What most bothers Sharon Turner, DDS, JD, is esthetic dentistry that’s performed in the absence of basic disease control, which requires a thorough examination of the patient and possible follow-up care as necessary. "Each patient should receive an individual assessment—which we teach our students—that addresses what their disease status is, what their functional/occlusal status is, and what conditions and contributing factors they may have—such as esthetic concerns," Turner says.
Ronald E. Goldstein, DDS, advocates a thorough patient examination that includes intraoral camera inspection of any pre-existing restorations, as well as follow-up prior to the development of any treatment plan. This follow-up, he says, could take two or three visits in order to ensure that the patient is in proper disease control and to enable further evaluation of the tissues’ function.
"We want the mouth to be as healthy as possible," Goldstein urges. "One of the advantages of following this course of action before any treatment plan is developed or discussed is that the patient gains confidence in the practice and a new understanding of what treatment means."
Nature of the Procedure Proposed to Treat It
"Although it’s not always true anymore, we have to assume that patients do not know dentistry or the consequences of treatment or no treatment," explains Dunn. "All that they assume is that when they get through it, everything will be good, it will last forever, and they’ll be happy and comfortable. The dentist’s job, as an ethical practitioner, is to make sure their patients understand the ramifications of the therapy."
Also, it’s important that treatment plans be developed that will deliver outcomes based on realistic expectations. Too often patients become disillusioned about esthetic dentistry and the manner in which their smile can be altered, explains Van Haywood, DMD.
Further, Turner notes that students are taught in dental school to develop a treatment plan that is custom-made to address what’s discovered during the individual patient assessment. "Everything is customized and nothing is cookbook," she says. "We encourage graduates and practicing dentists to remember what we taught them about diagnosis, assessment, and treatment planning. Just because a patient may present with esthetic demands doesn’t mean that you should look at those problems in isolation—look at the whole situation and determine in the complex of the whole situation what makes sense."
And the whole situation, Goldstein suggests, includes the presence of any pre-existing restorations that might later be perceived negatively by the patient after esthetic treatments are completed, as well as the potential impact of such conditions as bruxism on the longevity of requested and potentially conservative restorations such as laminate veneers. "It’s more conservative to propose saving enamel by placing a laminate with very little reduction, and I certainly believe that," he says. "However, if we’re not sure how long it will last because the patient clenches or grinds their teeth, that poses an ethical dilemma and a question that should be presented to the patient." Goldstein adds that he feels it’s important to offer an all-ceramic full crown as a viable long-term option when a laminate may not provide the patient with the life expectancy he or she expects.
Alternatives to the Proposed Treatment
Simonsen says that at least reasonable alternatives must be described to the patient as objectively as possible, and these alternatives must include the option—where appropriate—to do no treatment at all. "Of course, some of those other options may go against the financial self-interest of the person that is going to carry out the treatment," Simonsen notes. "In an elective treatment, the option of doing nothing must be presented as a viable option."
According to Bruce Small, DMD, clinicians must inform patients of all of their options. "You don’t want to perform a procedure and then have the patient come back and ask, ‘Why didn’t you tell me I could have had an implant instead of a three-unit bridge?’" he says.
Advantages, Risks/Benefits, and Disadvantages of Performing or Not Performing Proposed and Alternative Treatments
For most dental problems, there are multiple options, explains Harald Heymann, DDS, MEd, and those options may vary in durability, cost, and prognosis, among other factors. "I believe dentists should provide the patient with realistic options, all of which will provide good service—some better than others—but then cater those options according to the patient’s economic status, medical status, and what they desire," he says.
To best communicate many of these aspects of dental treatments, Dunn suggests that a "show and tell" using visual media (eg, photographs, videos, before-and-after) is effective for patient education. What’s more, this presentation should also include examples of potential failures in order to add one more level of information to the disclosure process.
Costs of Each Alternative— Including Potential Costs Over the Patient’s Lifetime
According to Simonsen, the selling of esthetic dentistry, by definition, runs a high chance of putting the dental health of the patient at risk in order to achieve a short-term cosmetic benefit. "As long as patients are ethically educated, given full and appropriate informed consent—including the potential cost of re-treatment for their lifetime, and if it is their choice and the clinician is convinced that the procedure can be completed without harming the patient, then I think it can be done," he says. "Education and objective informed consent are the keys to ethical treatment."
Assessment of the Patient’s Full Understanding of His/Her Condition, All Options, and His/Her Choice in Accepting Treatment
This is the last component of informed consent, Simonsen says. But he cautions that clinicians can very easily make their explanations for alternative treatment options persuasive in favor of any direction they desire, as outlined in the book by Ozar and Sokol entitled Dental Ethics at Chairside: Professional Principles and Practice Applications.1
For example, he recalled a paper he once read in which the author went to great lengths to justify the placement of multiple porcelain veneers in a young woman for whom composites would have been more conservative. "A young patient excited about getting a new smile doesn’t understand that there may be more conservative options," Simonsen explains. "In this case, I think the patient’s age led to induced consent rather than informed consent." Therefore, clinicians may also want to consider the patient’s maturity and decision-making capability when assessing their understanding and treatment choice.
A patient’s selection of the option that will meet his or her needs will be based on numerous factors. These include age, cost, medical condition, esthetic/restorative priorities, and material and procedure considerations, among others, Heymann says. The ethical clinician will help guide the patient through the joint decision-making process by enabling them to consider these multiple factors so that they will arrive at a treatment plan that best suits their needs.
Dunn points out that when "selling" esthetic dentistry, there is a great psychological aspect that can’t be taken lightly. Rather, it can be easy to take advantage of the vulnerability of the patient who wants to look better. "Dentists must use their best judgment to make sure that patients are not psychologically compromised in their decision about what kind of treatment they want or need," Dunn says. "From a biological standpoint, much of esthetic dentistry is want dentistry, not need dentistry."
Considering Material Selection and Technique Application
Education and discipline are what clinicians do, and how they do it is key to successful outcomes both esthetically and functionally. Being able to perform esthetic dental procedures using today’s modern materials and techniques requires knowledge and training.
"With the advancement of materials today, the great part about dentistry is that all dentistry is much more esthetic than it ever has been before," observes Matt Messina, DDS. "Dentistry traditionally has been more of a reparative profession in which if something breaks, then we fix it, or if it decays, then we repair it. With the materials we’re using now, we can restore teeth to the extent that they appear (ie, esthetics) and function as if they were never damaged in the first place."
But functional and esthetically successful restorations placed using today’s materials require clinicians to understand the materials they’re using, explains Gerard Kugel, DMD, MS, PhD. This includes understanding the chemistry and compatibility of the materials, he adds.
"It’s not fun or exciting to learn about the chemistry of dental materials or where problems may arise, but dentists need to know this information," Kugel asserts.
The American Dental Association (ADA) does not specifically support, organize, or endorse any one specific continuing education (CE) venue related to cosmetic or esthetic dentistry. However, Messina says that the ADA’s Continuing Education Recognition Program (CERP) does evaluate different CE providers offering courses or programs in esthetic and/or cosmetic dentistry subjects so that participating dentists can be sure that a particular course is being provided in a manner consistent with the ADA CERP quality standards.
"However, it’s the individual dentist who is responsible for making sure that his or her training is at the level it needs to be in order to provide care for the patient," Messina explains. "The ADA’s view is that it’s incumbent upon a dentist performing a procedure—whatever it is—to be very confident that they’re providing care at the highest level possible."
There are many ways to achieve this, he says. Dental schools today are teaching procedures that were unknown in years past. As a result, students are becoming better trained in and ready for esthetic dentistry when they graduate. Dentists in private practice are also adding newer techniques to their toolbox, he says, in order to take the best care possible of their patients.
According to Douglas A. Terry, DDS, sound dentistry has not changed—only improved. It is a universal concept founded upon scientific, evidence-based procedures that have long-term clinical success if properly utilized, he says.
"Research and clinical studies initiated in the 1960s by Cvar and Ryge define the criteria for clinical acceptability of biomaterials with different materials and clinical procedures," Terry explains. "These criteria for evaluating anterior and posterior restorations were adopted from rating scales in actual clinical studies of 5 characteristics that include color match, cavosurface marginal discoloration, anatomic form, marginal adaptation, and caries."
"If dentists are going to promote themselves as providing esthetic dentistry, then they really need to know what they’re doing, have an understanding of what the materials are that they’re using, and know how to place them in the proper environment," Kugel emphasizes.
Interestingly, there are materials available in dentistry today that are not only esthetic but that may also inherently enable clinicians to be more ethical in their treatments because they are extremely conservative—requiring less aggressive tooth reduction, believes Bruce Small, DMD. "I wouldn’t have said what I’m going to say now 20 years ago, because back then I was placing tooth-colored restorations—both direct and indirect—in almost every patient," Small admits. "Now I’m placing more gold restorations in patients, and I’ve found that some of those, particularly gold foils, can be extremely conservative."
But such materials have a long-standing history of performance in dentistry. According to Van Haywood, DMD, what’s lacking in today’s tooth-colored esthetic world is a breadth of clinical research on which dental practitioners can base the restorative choices they present to their patients. There’s little governmental support for restorative research these days because the emphasis is on disease and prevention. As a result, much of what is known about products today is anecdotal, he says. What’s more, he believes the industry is facing an interesting crisis in that more attention is placed on salesmanship than science.
"Patients are at risk because products are being developed faster to meet market demands, but that means we don’t have the time to evaluate if what’s being developed is going to stand the test of time," Haywood explains. "So, when selecting their esthetic materials and techniques, clinicians should always look for evidence-based dentistry or related research to determine if it’s a reasonable treatment to provide and one that won’t have long-term unanticipated sequelae."
The Ethical Lines of Esthetic Dentistry and Being an Esthetic Dentist
The American Dental Association (ADA) does not have a specialty classification for cosmetic or esthetic dentistry. According to Matt Messina, DDS, consumer advisor for the ADA, there’s a fine line between statements that promote esthetic dentistry, which represents a description of a type of procedure, and those that promote someone as being an esthetic dentist, which may imply a specialty where none exists.
"It’s perfectly acceptable for someone to say that they perform esthetic dentistry or cosmetic dentistry in the same way that they would say that they perform family dentistry or pediatric dentistry," Messina explains. "The spirit of the ADA Principles of Ethics and Code of Professional Conduct says that anything that would deceive the patient into believing something that’s not true (eg, that there’s a specialty in esthetic dentistry) is clearly an ethics violation."
Part of the conversation about the ethics of esthetic dentistry addresses over-treatment (ie, use of too many restorations or those requiring aggressive reduction of otherwise healthy tooth structure). While the ADA and the Code of Ethics provide an ethical boundary for what dental practices should be doing, Messina says that any procedure to be performed—whether it’s cosmetic, reparative, or any other form within dentistry—is up to the discretion of the individual dentist, the decisions he or she makes in consultation with the patient about what to do, and the subsequent treatment plan that’s developed based on that specific situation.
"The ADA is an organization of dentists committed to improvement of the public’s health through mutual support and the advancement of the process of dentistry," Messina explains. "Patient protection is part of that. However, from a legal standpoint, the powers, privileges, and rights of the practice of dentistry are established on a state-by-state basis by the state board of dentistry for each state."
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