Esthetic Dentistry: When Is Too Much Too Much and What Is Enough?
Never make technical decisions thinking in profits; you will pay for it.
The main objective of this chapter is to enable dental students to make ethical decisions when patients have esthetic issues. This involves first getting to know the patient, establishing what the patient really wants, and determining the patient’s overall circumstances. Then, dentists must have the appropriate skills to resolve those issues and meet their treatment needs. Considering that technological advancements continue to increase the possibilities for making a smile more esthetic, it is a disservice to possess skilled knowledge without properly applying it.
What constitutes an esthetic concern? Who is the judge?
What does the patient want? How do you find out?
What are the patient’s overall circumstances? Why is that important?
Do you offer the most modern dentistry or the minimum amount of dentistry to satisfy the original goal?
What is your skill level? What if you have advanced skills and knowledge and you do not apply them for the patient’s good?
When is the line crossed to malpractice by simply covering everything with no-prep porcelain veneers to give the patient a straight, white smile?
What is a fair fee? What is it based on?
What Constitutes an Esthetic Concern? Who Is the Judge?
After four or more years of dental school, dentists’ eyes may be cursed to focus on a person’s teeth before looking at their smile, eyes, face, or other interesting aspects of their human form. Even after many years of professional practice, they may catch themselves staring at the teeth of the person they are talking to. Or when watching a movie in which the face and teeth are enlarged to appear two stories tall, dentists may analyze the teeth, gums, and lips to determine what has been done and how they could do it better.
This epitomizes the fascinating and incredibly complex world of ethical decision making in esthetic dentistry. For the purpose of this chapter, esthetic dentistry is the process of changing the appearance of the patient’s smile and changing the patient’s perception of his or her smile. Some might argue that all dentistry should be esthetic dentistry, because if time is taken to restore or repair aspects of the teeth or smile, it should simultaneously be accomplished to look good.
It is to be noted that the definition of esthetic dentistry does not describe how to achieve esthetic outcomes. Technological advancements in bonded porcelain veneers, CAD/CAM-designed orthodontics, orthognathic surgery, implants, composite bonding, and other restorative techniques enable dentists to create magical smiles. It would be easy to highlight case after case of beautiful full-mouth restorations, or before and after pictures involving orthodontics, whitening, laser gingivoplasty, and combinations of porcelain bridges and veneers in which the teeth are literally transformed into things of beauty.
Instead, what defines esthetic dentistry—and how the results the patient wants are achieved—are answers to important questions that must be addressed before deciding upon the dental problem and initiating treatment. Surprisingly, I learned some of these questions from some of my most disadvantaged patients and from my hygienist.
What Does the Patient Want? How Do You Find Out?
How many times has a stranger asked you, “How are you doing?” to which you automatically respond, “Just fine,” when in reality you might be suffering from the worst hangover or a bad cold, or just lost your favorite pet? People do not always tell you what they really mean.
For this reason, if you were to walk the halls of my office, you would find a beautiful and clean space, a small team of well-trained professionals, portraits of smiling patients, fresh flowers, pleasing aromas, and a view overlooking a pool and tropical garden. The question you will hear repeated more than any other is, “What do you want?” It is the one simple question repeated more than any other because it is carefully designed and orchestrated to dig into the inner psyche of the patient.
Ultimately, understanding the patient’s psyche is important to providing what they want. Dr. L.D. Pankey, in honor of whom the Pankey Institute was named, was an extraordinary communicator whose philosophy for a successful dental practice included a 4-way balance. This involves knowing yourself/knowing your patient, which is intersected by knowing your work/applying your knowledge. Before ever beginning to treat patients with the skills dental students are so anxious to apply (and get paid for), they must get to know them and what they really want. What patients really want may not be what dentists think is obvious or what they see as the dental problem. That is why the same question is repeated so many times.
When a new patient comes into the office and after the usual greeting, repeating the question might be woven into the conversation like this:
You: What do you want?
Patient: I want to have my teeth cleaned.
You: Great! We can do that. Why do you want to have your teeth cleaned?
Patient: Well, they are starting to look a little yellow.
You: Yes, I see that. Is there anything else?
Patient: They are not as straight as they used to be. And these old fillings are turning black.
You: I am curious, why is that important to you?
Patient: I do not want to look old.
You: If there were a way to make your teeth white and straight and not have the black fillings, is there a certain time that you would need that by?
Patient: Why yes. I have an important reunion coming up in three months!
This scenario is actually very real and quite common; the patient initially said that they wanted their teeth cleaned, when in reality what they really wanted was to not look old and have a smile with straight white teeth in time for a reunion. How many times would you have to ask variations of the same question, “What do you want?” before getting the real answer? How easy and tempting it would have been to stop asking questions after any response and start offering dental solutions?
If you further break down the conversation, after the first response of “I want my teeth cleaned,” you could have immediately started talking about the wonderful new technology of ultrasonics and the latest polishes and remineralizing pastes, DNA testing, and C-reactive protein testing. The hygienist then could have cleaned the patient’s teeth, feeling smug and professional that he or she gave the patient what they wanted.
However, this conversation in its entirety represents only the first round of questions. You still really do not know the patient well enough yet, but such a conversation illustrates how most esthetic dentistry comes about. Typically, a patient enters a practice in this manner; it is not the norm for someone to call up and say, “I would like to make an appointment for 12 porcelain veneers.” Esthetic dentistry evolves from a process of determining what the patient wants, which is usually “a nice smile,” followed by a dialogue about how that can be accomplished and how much it would cost.
What are the Patient’s Overall Circumstances? Why Is that Important?
What patients want and how it can be accomplished depends on their overall circumstances. Dentists cannot be the judge of what will satisfy a patient’s esthetic concern without knowing his or her overall circumstances. To fully ascertain a patient’s circumstances, the rule should be patients talking 80% of the time, dentists talking 20% of the time. By following this formula, dentists and their staff will appear smart and establish a successful relationship with their patients.
Consider a patient’s esthetic circumstances. A patient may have a huge diastema between their central incisors and initially say that they want to close some spaces. Do you immediately tell the patient how you can do that with bonding or other treatments? Do you learn more about the patient? For example, maybe the patient wants to keep the diastema as a character trait and close the spaces on the other teeth.
Consider a patient’s financial, social, medical, and home circumstances. A patient may have just lost their job, be going through a separation, be behind on bills, or just told they have a serious medical problem. How do such circumstances affect what the patient wants and what constitutes an esthetic issue? Would it be a disservice to present a large bonded porcelain veneer case with a large fee?
Do You Offer the Most Modern Dentistry or the Minimum Amount of Dentistry to Satisfy the Original Goal?