When is Too Much Too Much and What is Enough?
Randy Mitchmore DDS MAGD
Purpose: 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.
1. 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’re 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.
When confronted with a bad veneer treatment that a patient thinks looks wonderful, a dentist may internally roll his or her eyes, or “tsk tsk” to themselves when wondering why a smile makeover wasn’t performed, especially on a celebrity or someone with obvious financial means to do anything they want. After all, how could this person spend so much time and money on hair, make-up, clothes, skin products, nails, shoes, cars, and vacations and have awful looking teeth. To esthetically minded dentists, the worst offenders are other dentists with bad teeth, who don’t see when they look in the mirror what their colleagues are seeing.
This epitomizes the fascinating and incredibly complex world of ethical decision making in Esthetic Dentistry. For the purposes 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, since if time is taken to restore or repair aspects of the teeth or smile, it should simultaneously be accomplished to look good.
Note 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 very skilled, gifted, and talented hygienist, Janie Robinson, RDH.
2. What does the patient want? How 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’d 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.
Understanding the patient’s psyche is important to understanding—and ultimately 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 four 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 to 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’s 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 break the conversation down further, 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 don’t 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.
3. 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 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?
4. Do you offer the most modern dentistry? Or the minimum amount of dentistry to satisfy the original goal?
Some of the most important principles of esthetic dentistry can be learned from some of our most disadvantaged patients. The American Academy of Cosmetic Dentistry has a wonderful Charitable Foundation that supports the Give Back A Smile program, which consists of a volunteer network of dental offices and laboratories that will help a survivor of domestic violence with a damaged smile, pro bono. In some of these cases, complex esthetic restorative dentistry is required. In others, the extent of dentistry required to achieve an esthetic transformation is minimal.
Consider Suzanne, who suffered a Class IV fracture to her central incisor when her husband hit her several years ago. To a dental professional, it appears to be a rather routine small fracture.
What do you see when you analyze this case closely? Do you see the reverse smile line? Would it look better to lengthen the centrals and laterals to follow the beautiful curvature of the lower lip and be in line with the incisal tips of the posterior teeth? Would it be better to veneer all of the teeth that show in the smile, in this case all the way back to the molars?
Would it be wrong to prepare or grind down perfectly good and beautiful enamel on all of the teeth to achieve a better look if that is what the patient wants? Would you encourage or recommend that? Why or Why not?
What material would you choose: bonded porcelain, bonded composite, full-coverage, prep, minimal prep, or no-prep restorations? What part does your skill level play in the decision process?
If this will be a laboratory case, what kind of laboratory will you use: a foreign laboratory that charges $49. per unit or an accredited custom laboratory that might charge 20 times that amount? What will your fee be?
Now consider the patient’s circumstances. For Suzanne, every time she looked in the mirror, the fractured central incisor was a constant reminder of the abuse she endured and a horrible time in her life. It continued to give her a message of unworthiness and defeated self-esteem. Bruises and scars can heal on their own and go away. A broken tooth cannot fix itself. In psychological terms, it is described this way: “An impaired self-image may be more disabling from a developmental aspect than the patient’s actual physical defect. The more attention is focused on a particular area, the more people tend to acquire a negative self-image relative to this area. In general, the clinician is not aware of the degree of the patient’s perception of dentofacial disfigurements. The effect of such restorations may be underestimated in terms of their potential benefit to mental health.”1
Suzanne’s “esthetic” issue was the constant reminder of abuse she saw—the fractured incisor. In considering her circumstances and what she really wanted—to smile again and feel good about herself—it was determined that a thorough cleaning, tooth whitening, and direct composite restoration of only the fractured tooth would truly complete the restoration of her life. This represents true esthetic dentistry because it is the process of changing a life, not the nuts and bolts of how to fix a tooth, and is best described in Suzanne’s own words:
In two weeks, Dr. Mitchmore and his wonderful staff gave me the most beautiful smile! Antonio made me whitening trays to use for two weeks, and Cristina cleaned…and cleaned. The bonding procedure was done very subtly, with different shades and transparencies and took two hours of concentrated work by Dr. Mitchmore and both dental assistants. When his assistant, Silvia, first handed me the mirror after the bonding procedure, I cried, and she kindly told me that there had been many tears of happiness there. I had forgotten how it felt to really smile—this realization is so profound. My family is very thankful, as well, and is amazed by how natural it looks. I had forgotten that my youngest child had never seen me any other way, so you can imagine how wonderful all this is to me. Dr. Mitchmore and his entire staff gave selflessly of their time, skills, and caring to help me again become the person I really am—happy, outgoing and productive.
Suzanne’s words describe the real soul of esthetic dentistry, which is finding the sweet spot of where the appropriate dental technology and skill matches perfectly with and brings about that inner satisfaction and pride within the patient. She writes more about the change in her feelings about herself and how others perceive her than how the restoration looks. She also talks more about how she was treated and how hard people worked just for her!
5. What is your skill level? What if you have advanced skills and knowledge and you do not apply them for the patient’s good?
One of the interesting things about dental practice is that dentists realize they become better than they were 10 or five or even two years ago. They can look at some cases they did 10 years ago and realize that now they could do them better and perhaps want to do them over. However, they take comfort in knowing they did the best that they could with the technology and circumstances of the time, and most patients understand that. Just like today’s computers are better than the same computer 10 years ago, I have had a number of patients have an esthetic case redone because better things are now available.
The other side of the knowing the patient equation is knowing yourself, and it is incumbent upon you to deliver the best dentistry that you know how to perform. At this point in your dental career, you do not know how to do everything. In fact, there are some technologies or procedures that most dental students do not even know are possible. How they wrestle or come to peace with those facts is part of being a caring professional. Likewise, it’s equally important to determine how much or how little dentistry is needed to achieve an esthetic solution.
Consider this scenario. A dentist is donating their services to treat a survivor of domestic violence and the laboratory will donate any lab work to help this survivor. The fee is not an issue and the dentist can to do anything they want. They have just taken some hands-on courses in dental implants and some courses on sculpting ovate pontic receptor sites. They would love to practice their new skills without financial pressure if things don’t turn out perfectly. The patient will be grateful for anything that might be provided for her.
Trisha is a survivor of domestic violence a number of years ago that left her embarrassed about her smile. She lost her home and lives with her daughter. She loves to sing in the church choir and is very concerned about being able to sing every Sunday. Trisha lives 60 miles away in a community that was recently economically devastated, and her daughter had to give her a ride to the dental appointment, dragging her hyper five-year-old son with her. They are an hour and a half late for the examination appointment, during which the boy trashes the reception room and eats and drinks the refreshments that were so tastefully set out.
The oral clinical findings included moderate periodontal infection, moderately acceptable oral hygiene, a few treatable caries, and tongue thrust. Teeth Nos. 2, 3, 7, 13, 14, and 1 were missing, and tooth No. #9 had a broken off root tip.
Considering the overall circumstances, what would you do? What is the best treatment plan for all concerned? Is there a difference?
Now, evaluate the postoperative photographs, noting that the esthetic results were achieved from a treatment plan involving extractions and a complete full denture! The patient’s beautiful smile emphasizes the fact that full dentures can be an equally esthetic solution as full-mouth bonded restorations, implants and bridges and should be considered based on patient circumstances and needs.
Dentists have no way of knowing how a minor dental defect or multiple missing teeth are impacting a person’s life until they begin to ask questions and get to know them. In the first example, a woman felt devastated by a small chip in a tooth. In the second example, the patient was totally missing a front tooth, embarrassed about it, yet maintained a more laid back and happy-go-lucky attitude about it. However, after being restored, her life was also transformed into something more wholesome and productive that surprised her. Perhaps she was in denial about how her appearance was really affecting her self image.
Now, understanding the role that circumstances play in determining and treating esthetic issues, what other treatment options would have been equally successful?
6. When most people receive something that they like, they want more of it. What are examples of that? How does that relate to esthetic dentistry?
Most people that receive something that they like want to receive more of it. If they receive love, they like getting more of it. If they receive health after being sick, they want to be healthier.
Here is the fun application to esthetic dentistry. Most people when they think they want their teeth just a little better, usually want them even better when they attain the first goal.
For example, many times patients will be fitted with a full mouth provisional restoration that is just a bit whiter than their natural teeth because the patient said that would make them happy. Typically when they return for a provisional check, they almost universally ask, “Can it be made even whiter?”
But keep in mind a Texas saying shared by an attorney: “You can shear a sheep many times, but you can only skin it once!” In other words, as long as you charge a fair fee, a patient will return to you many times for care. However, if you take advantage of or gouge a patient, you will only do it once and your reputation is damaged.
7. When is the line crossed to malpractice by simply covering everything with no-prep porcelain veneers to give the patient a straight, white smile?
Bonded porcelain can achieve beautiful, esthetic results while totally restoring a malocclusion. I believe this so strongly that I have had my own teeth restored in this manner. I also subscribe to the concept of minimally invasive dentistry in which minimal preparation porcelain veneers are extremely esthetic and very healthy for the teeth and soft tissue. However, they require the same attention to detail and expertise as some full preparations.
Unfortunately, current trends have twisted the noble concept of minimal dentistry. Some dentists and laboratories promote no preparation of teeth, with the laboratory making very white, opaque and bulky porcelain veneers that simply cover the teeth and everything underneath, including old amalgam, composite fillings, and even decay. Such procedures can be highly profitable for dentists. While marketing messages touting “no shots, no drilling” and beautiful white teeth could satisfy a patient’s esthetic desires for straight, white teeth with no pain, are such procedures the right thing to do, even with a very broad informed consent?
Here is one such example. Anthony is a bright, handsome law student. About a year ago in his home town, he had no-prep porcelain veneers placed on his six anterior maxillary teeth to close a diastema. He was pleased with the result, but two of them popped off on teeth Nos. 10 and 11. He comes to you to have them replaced. He has been saving his money, which is hard because he is a student and has a small budget to replace the missing veneers.
Of course, a clinical examination is required, in addition to asking the patient what he wants—or perhaps what he wanted from the no-prep veneers. In conducting the examination, consider the following.
What do you see?
Why did the veneers pop off?
What is the orthodontic classification? Why is that important?
What is the darkness at the gingival portion of the central incisors?
What is the periodontal condition? Why?
What is the ratio of the height vs. the width of the central incisors? What is ideal?
The patient was happy with the esthetic result. What are you going to do for him?
Dentists new to the profession may not know the answers to some of these questions about this case and, further, may not know that these question need to be asked. What is your ethical duty when you are thrust into situations such as this?
It is your professional duty to tell the patient what you see and, clearly, there are a lot of issues that the patient does not see and is mostly unaware of. The caveat of educating the patient about their condition is doing so without making disparaging remarks about the former dentist or making it sound like you are trying to do more than what the patient wants for your own financial gain.
The solution that worked for this case was asking the patient’s permission to tell him everything the dentist observed and having a frank discussion of the oral findings. Of course, it was the dentist’s duty to do that anyway, but by asking if the patient wanted that, it opened the door to engage the patient and let him know that the dentist wanted to be his counsellor, not just a “repairman”. The dentist acknowledged the problem of the two missing veneers and informed him that other problems existed with periodontal disease, decay from microleakage, a bad bite that would make it difficult for any veneers to stay on, and width and height ratios that were not attractive.
The dentist and patient discussed the real solution that could involve orthodontic correction, a full-mouth restoration to increase the vertical dimension and bad bite, removing all of the veneers, making treatment provisionals to facilitate treating the periodontal problem, and then making new veneers that did not violate biologic principles. Since he was a student on a small budget, both agreed to make short-term and long-term plans, which included recontouring all of the existing veneers under local anesthesia, teaching him the hygiene requirements, and replacing the two missing veneers. As time and budget allowed after he began working, the long-term plan was to address the underlying issues discussed. Even though he said what his budget was, the patient was able to stretch his budget higher as needed to cover this first phase of treatment because he understood its importance and valued it. Here is the result of the phase one treatment after six weeks
8. What is a fair fee? What is it based on?
A discussion of fees is included in this chapter because it is part of the esthetic treatment process and an area that can cause very bad feelings if not handled in an upfront manner. If patients are surprised, have a misunderstanding, or are unhappy about how the fee is handled, it can easily transform into perceptions of bad treatment, even though that may not be the case.
Fees are an important part of treatment. If it is too low, the treatment is not valued. If it is too high, dentists risk losing or embarrassing the patient, or creating a disgruntled patient who damages the dentist’s reputation. Therefore, it is important to begin discussing fees early in the treatment planning conversation, not later, to help avoid the topic of fees becoming the big elephant in the room that no one wants to talk about.
It works well to talk in general terms first to see where the patient is at. For example, asking the following question gives a wealth of information about a patient’s perception of the value and cost of certain treatments: “Would it surprise you that some people pay the price of a small car to have a smile like this?” Do not create an elaborate and detailed case presentation, then drop the bomb of the fee at the end of your conversation, when the patient has no earthly idea how much it may cost. Additionally, there are ways of discussing the fee early in the treatment conversation without detailing a cafeteria like itemization of procedures, which would be a mistake.
Esthetic dentistry costs are, and should be, highly variable. Most large law firms have different hourly fees for attorneys doing the same work in the same firm, with a senior partner charging double or triple the hourly rate of a new attorney because the senior attorney has a higher skill and experience level. They are selling a service and not a commodity.
A dentist’s fees should be set on certain identifiable business factors, not a fee schedule from an insurance company, for the same reasons. Variable factors include skill and experience, level of care expected, the expected time involved, and how demanding the patient is for something clinically acceptable or close to perfection. Fixed and variable overhead costs and laboratory fees should indicate what the hourly rate should be to cover these expenses. Combine these factors together determines the fee for an esthetic case.
Dr. Pankey believed that a fair fee is any fee a patient is willing to pay with gratitude. If a patient hastily scribbles out a check or shoves a credit card to the business assistant and angrily says, “Here’s your money,” a fair fee wasn’t negotiated, most likely because the dentist didn’t build value for the treatment, not the particular dollar amount of the treatment.
Imagine that a young woman—an hourly worker with a child to care for—desires esthetic dentistry, but she has a high fear of dental care. The fee given is significant for her budget and requires some sacrifice because it is much more than she thought about spending for dental care.
A desired outcome is the following. Do her preliminary phase one care of periodontal health and caries removal under IV sedation. Become her friend, advocate and cheerleader. When she brings her check in to begin the esthetic phase, she also brings a large beautiful platter of fresh fruit as a gift to the office that treated her so well and to show her gratitude and excitement for what was happening to her life. The dentist smiles with gratitude, knowing it’s going to be a beautiful case because the patient is getting something she wants badly and is happy to pay for it.
In making an ethical decision of what to do for a patient, I like to recall the Rotary International Four Way Test of the things we think, say, or do.
Esthetic Dentistry is such a fascinating aspect of our profession because frequently there is no one clear answer to a problem. The dentist and patient make choices based on the overall circumstances. It is your professional duty to make those choices based on ethical decisions. When those trusts are violated, dentists open themselves up to shame, misery and a bad reputation. When dentists make choices and treatment recommendations that give the patient what they want through utilization of unique talents and skills as an esthetic dentist, it creates a win-win for all that can be both spiritually and financially rewarding.