Where is the professional and public outrage at the troubling trends in the marketing and selling of “cosmetic” dentistry that besiege our profession today?
The code of primum non nocere—first and foremost do no harm—seems to have been cast aside in the headlong pursuit of outrageous overtreatment for financial gain by some. Fortunately, this trend is manifest by a small, although unfortunately highly visible, minority in the profession. Their actions, however, affect all in the dental profession, as the public begins to understand what is being sold to them in the name of “changing lives.”
The American Dental Association’s “Principles of Ethics and Code of Professional Conduct” states,
The dental professional holds a special position of trust within society. As a consequence, society affords the profession certain privileges that are not available to members of the public-at-large. In return, the profession makes a commitment to society that its members will adhere to high ethical standards of conduct .
Thus, there is an implied contract between the dental profession and society. One would expect, therefore, outrage, or at least umbrage, to be shown by society (and from fellow members of the profession) if the implied contract is pushed to its limits, as I believe is happening today, with the balance between commerce versus care tilting toward commerce at the expense of care.
There are several ethical issues that should concern us all, such as
the use of false or nonrecognized credentials promoted by nonaccredited institutions
reliance on unproved science to promote treatments
exaggeration of clinical skills and education
unnecessary treatment and services
lack of full informed consent
harmful practices, such as the unnecessary removal of tooth structure and the replacement of highly clinically successful materials (such as gold) with inferior, untested restorative materials
exposing patients to the unknown risks of overtreatment
failure to refer to specialists
When considering elective cosmetic enhancement, patient health always should come first in the mind of practitioners and always should trump patients’ cosmetic desires, even at the expense of patient autonomy. Woe to clinicians who allow personal economic goals, masked beneath patients’ naïvely expressed cosmetic desires, to lead to unnecessary or excessive treatment. We, as a profession, have an ethical duty to weigh the benefits and the risks of any procedure, and if the potential harm or risks outweigh the benefits, even patients’ requests for treatment should be declined. That decision is the appropriate application of professional judgment by the dental profession, on which society relies, in the manner of the implied contract with the profession.
I am not an expert in ethics. I did not know as a college student that I one day would regret having focused so much on the sciences at the expense of the arts—in other words, I did not know what I did not know. Much to my later chagrin, I never took even as much as an introductory course in philosophy. So, my opinions come from inside. They are based on what my parents, and my school, Portsmouth Grammar School in Portsmouth, England, taught me about what is right and wrong. So, like my interest in grammar, where I do not really know all the rules but I certainly know what is right and wrong by how something sounds, so it is with ethics. I do not know all the rules. I have not read the writings of Aquinas or Aristotle, Descartes or Kant. I simply am relating how I believe ethics affects us as dentists in the practice of our profession based on my inner feelings of what is right and what is wrong. And where I see wrong, I believe it is my, and collectively our, duty to say something or become a part of the problem as enablers of unethical diagnosis and treatment.
The field of ethics involves concepts of right and wrong behavior. Generally, the field, as I understand it, is divided into three general subject areas: metaethics, normative ethics, and applied ethics. The areas that I focus on are the area of normative ethics and the subareas of duty theories and consequentialist theories (yes, I looked up the official terminology!) .
The seventeenth-century German philosopher, Samuel Pufendorf, classified dozens of duties under several headings. I confine this discussion to Pufendorf’s descriptions of duties toward others and his rights theory . Rights and duties are related inasmuch as the rights of one could be the duty of another. A “right” is a justified claim against someone else’s behavior—for example, patients’ right not to be harmed by dentists. Duties can be divided into absolute duties that are universally binding on people and conditional duties that stem from contracts between people (keeping promises). One can recognize in the absolute duties (avoiding wronging others, treating people as equals, and promoting the good of others) the basis for how most of us are raised by our parents, and I believe I can recognize in how these duties were impressed on me the reasons why I feel the way I do about the state of our profession when it comes to ethics, in particular our ethical understanding of cosmetic dentistry.
A more recent duty-based theory is proposed by the British philosopher, W.D. Ross, which emphasizes prima facie duties . Ross’s list of duties is as follows:
fidelity: the duty to keep promises
reparation: the duty to compensate others when we harm them
gratitude: the duty to thank those who help us
justice: the duty to recognize merit
beneficence: the duty to improve the conditions of others
self-improvement: the duty to improve our virtue and intelligence
nonmaleficence: the duty to not injure others
Moral responsibility also can be determined by assessing the consequences of our actions (consequentialist theory). Accordingly, an action is morally right if the consequences of that action are more favorable than unfavorable .
Bader and Shugars state,
An implicit, if not explicit, assumption accompanying any treatment is that the benefits of the treatment will, or at least are likely to, outweigh any negative consequences of the treatment…in short, that treatment is better than no treatment.
Thus, if the potential harm from any treatment, in particular an elective intervention, exceeds the potential benefit, then it is unethical to carry out that particular treatment or enhancement. For example, placing 8 or 10 veneers for a patient who needs the esthetic enhancement of one tooth, thus starting the patient on a cycle of never-ending restorative treatment for many teeth from which the patient never can be extricated, properly can be termed, beneficence gone wild.
When I attended dental school (1967–1971), the prevailing doctrine of the times was a paternalistic, hippocratic approach to dentistry. We, as dentists, my teachers told me, know best and if patients do not like what we propose for treatment, they should be shown the door. Patients who are not good at following oral hygiene instructions are told they could not be treated until they shaped up. Patients even should be coerced into treatment (for their own good, of course) and patient autonomy was a weak principle in the dental educational system of the time. Dentists, or physicians, know best.
By the turn of the century, the pendulum thankfully had swung greatly from the paternalistic attitudes of decades past to increased patient autonomy and full informed consent for all treatment. Informed consent is the practice of informing a patient fully about all aspects of interventions relevant to patients’ choice between authorizing or refusing a proposed course of therapy and enabling them to make a choice about an intervention. Informed consent includes reinforcing the option of no treatment. It is dentists’ responsibility to decline to carry out a treatment if it involves the unnecessary, or avoidable, destruction of healthy tooth structure.
Unfortunately, my view of some cases I see presented in the dental tabloids leads me to the conclusion that many offices where cosmetic dentistry procedures are marketed pay only lip service to accurate and full informed consent procedures, and this is true in particular for the no-treatment option. In some of the cases I have observed, it is hard for me to understand that patients could have been informed appropriately, or they surely would have chosen alternative, more conservative options, including possibly no treatment, rather than starting on a life cycle of restorative treatment . This last option of no treatment is, of course, contrary to financial self-interests, although not of the ethical contractual bond, of dentists who are bent on increasing productivity.
Any elected treatment should be made only after full and complete informed consent, with all treatment options presented in an unbiased fashion. It seems as if some colleagues use claims of informed consent as a means to divert criticism. We must realize that informed consent is ignored, in many instances, by clinicians or patients. When I visit an expert, am I going to second-guess what I believe is the expert’s opinion? In most cases, I am not. As patients, we all tend to go along with what health care practitioners expert advise.
Recent trends to promote office production, above any concerns for patients, are troubling. As Fuchs notes in a recent editorial, originally published in the Missouri State Dental Journal, Focus MDA , and reprinted in the ADA News , “Could it be that over the last two decades dentists have drifted from being patient advocates to the current wildly popular ‘practice advocates’?” We are inundated with articles and magazines on how to increase office income, and it is not hard to see that the best-attended courses, when it comes to continuing education, always seem to be the courses that promise greater income and how to get patients to say “yes” to financially rewarding treatment plans. That is truly sad in a profession, such as ours, that is based in service, in preventing and treating disease, and in restoring health.
Ozar and Sokol proposed a hierarchy of values, which became an excellent tool for ranking professional values. Sometimes the choice is between the lesser of two evils when it comes to choosing between patient desires based on their knowledge level and the appropriate treatment from a clinician point of view. Ozar and Sokol’s hierarchy lists the values as follows:
the patient’s life and general health
the patient’s oral health
the patient’s autonomy
the dentist’s preferred pattern of practice
efficiency in the use of resources
The rule of the hierarchy is that it is unethical to take any action that puts a lower item on the list ahead of a higher item on the list. In other words, as an example, a patient’s oral health always trumps esthetic values. Similarly, a clinician is acting unethically if “he or she chose to provide treatment to a patient that enhanced the patient’s oral health and yet put the patient’s general health in jeopardy” .
If clinicians hang their hats exclusively on the duty of nonmaleficence, it follows that treatments of no effectiveness (as long as they do no obvious short-term harm and patients insist on getting the treatment) are acceptable. If, however, one holds to the duty of beneficence also, as we all should, then one must practice at a higher ethical standard than performing treatments that have no effect on patient health. How does one know, for example, that placing 8 or 10 veneers does no harm? What if the esthetic benefit is minimal or even nonexistent? Is there a benefit that outweighs the negative aspects of a young person having to live with the inevitable consequences of a foreign material (no matter how good it is) that is attempting to replace natural enamel? Worse is the fact that some clinicians use materials, such as pressed ceramics, that lead to preparations that necessarily must be cut into the dentin to allow for adequate thickness of the material. Thus, vast amounts of otherwise healthy tooth structure are sacrificed in the name of cosmetics—an enhancement that clearly violates Ozar and Sokol’s hierarchy.
As I struggle with my own thoughts on the issues of the ethics of cosmetic dentistry, I think back to a text that I wrote in the mid-1970’s, published in 1978 . In that text were several chapters on what today would be called cosmetic dentistry, inspired by what the new bonded resin materials could accomplish, for example, for patients who had a fractured central incisor, compared with the aggressive treatments indicated at the time as the standard of care. I have not checked, but I doubt that I used the word “cosmetic” in the book. That is because I never believed these treatments cosmetic, per se. In my mind, almost every clinical procedure we, as dentists, carry out has an esthetic component. What caught my attention were the minimally invasive options then possible that were of great benefit to patients in terms of the conservation of tooth structure with the use of resin composites and the acid-etch technique. Instead of a full crown on a central incisor, we simply could apply a resin composite and end up with an esthetic result that was in most cases indistinguishable from a crown. Of course, in those days, the color stability of the resins meant that the restorations had to be resurfaced or replaced in a short period of time. That is not true today with advances in application methods and with the excellent color stability of the modern resin materials.
In the early 1980s, John Calamia and I published the first information (in the form of an oral presentation and an abstract in the Journal of Dental Research ) relating to the potential for etching porcelain for “anterior veneers and other intraoral uses” . This was followed by Calamia’s landmark article on a clinical case. Again, at the time, my ideas were connected to the saving of tooth structure with these advances, not as much to the “cosmetic” benefits, as these benefits could be obtained in other ways using the esthetic techniques of the time, albeit sometimes with more aggressive tooth preparation. The idea for etching porcelain came from thinking about how we could improve the color-unstable resin composite veneers that were state of the art at that time. Using porcelain was an obvious benefit, but no one had thought of a way to accomplish that task. When thoughts of how to improve resin composite veneers were put together with the observation that dental laboratories routinely removed porcelain from discarded bridges to reclaim the gold with a liquid, the acid etching of porcelain for retention as a veneer became a reality. Calamia’s first clinical case of etched porcelain veneers was done without removal of tooth structure, although the standard of care today reflects the minimally invasive preparation within enamel that has become routine.
Perhaps this conservative, minimally invasive philosophy that I have is responsible for the visceral repulsion I feel from some of the enhancement cases (I would not call them treatment, as this suggests a health benefit) I see published in the tabloid press. This leads to the crux of the ethical argument today over cosmetic dentistry. Although I believe that most dentists who concentrate on cosmetic enhancements are ethical and honest in their approach, the few who push the envelope of ethical responsibility and overtreat patients for financial gain are responsible for creating an environment where the commerce of dentistry is put first and patient care second. Spear wrote an excellent commentary on this problem in a recent issue of the Journal of the American Dental Association , ending with, “Providing occlusal therapy is a health care service first, a business and financial resource second” .
I began this editorial with the question, “Where is the outrage?” Already, that question suggests a certain bias in the topic and the situation we are facing in dentistry today. I have no argument with general practitioners who wish to become more adept at esthetic procedures and who focus interest in taking courses designed to improve clinical skills in esthetic, or cosmetic, dentistry. Where I have issue is with those who go to a couple of weekend courses at an “institute” and then advertise that they are expert in full mouth reconstruction, a level of skill that prosthodontic colleagues study full time for 3 or 4 years in graduate school to attain. The most dangerous among us are those who jump on the cosmetic bandwagon and who do not know what they do not know. Training in a formal, accredited residency program should be required of those who choose to market cosmetic dentistry aggressively, and full mouth reconstruction should be left to prosthodontic colleagues.
So, where is the outrage at what is going on in our profession? The problem is not that cosmetic procedures should not be done; minimally invasive esthetic correction can be a wonderful service when diagnosed ethically and presented to patients. The problem is that cosmetic dentistry should not be aggressively overpromoted and sold to the public, as increasingly is happening today. Dentists need to get back to being patient advocates. In doing so, the practice income will take care of itself.
The ethics of esthetic dentistry needs to get back on course before outrage breaks loose and Big Brother decides to take care of us, because we cannot take care of the dental professional ethics and professional conduct ourselves. That will be a sad day for the profession’s autonomy. As one of the founders of the Mayo Clinic, William Mayo, once put it, “The best interest of the patient, is the only interest to be considered.” Where treatment planning in esthetic dentistry is concerned, that should be the profession’s mantra.