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Question: Responsible esthetics - Is there a return to conservative esthetic dentistry?
When establishing a diagnosis and developing a treatment plan, esthetic considerations must be balanced with the patient’s medical, periodontal, biomechanical, and functional considerations. Esthetic considerations should be presented within the context of health and wellness. Science and sound clinical judgment must be combined to help guide patients in making decisions which best serve their long-term interests.
Open and clear communication is important but is especially so when a patient is considering elective treatment. It is imperative that we have a clear understanding of our patient’s concerns, objectives, expectations, and preferences. As professionals we often have a more complete understanding of the contributing factors that influence esthetics and it is important to share that information in a careful and tactful manner. However, while doing so, the clinician must take care to avoid encouraging the patient to move beyond satisfying his or her needs. The patient must ultimately decide if these factors have importance.
We have a responsibility to help patients understand the risks, if any, of foregoing treatment as well as the risks associated with proceeding with treatment. While there is an obligation to discuss the objective capabilities and limitations of esthetic dentistry, it is prudent to allow each patient to explore the potential subjective benefits of elective treatment, as they vary widely from one patient to the next. The subjective benefits for one patient cannot be assumed to be true for the next. It can be misleading to imply otherwise. The skilled clinician must help the patient weigh all evidentiary and non-evidentiary calls to action in order to arrive at the best choice for that individual.
Multidisciplinary options intended to prevent the unnecessary removal of healthy tooth structure should always be considered. There is an established relationship between increasing degrees of tooth reduction and unfavorable sequelae. Patients need to be counseled regarding all the inherent risks associated with treatment in terminology that they are able to understand.
Lastly, clinicians have an obligation to refuse treatment requests that do not serve the patient’s long-term interests. At the end of the day, we must know that we have done our best in guiding our patients to a lifetime of health and well-being.
A particular concern to me has been the “over-lamination of America.” There seems to be an overwhelming exuberance for some dentists to completely restore the smile using porcelain veneers rather than less invasive procedures. Although the most financially rewarding for the dentist, this “quick fix” approach may not be the “best fix.” Each treatment plan should take into consideration the long-term priorities of the patient, including the reality that restorations need to be maintained and replaced in the future. Many patients have come to me to re-do failures, especially where occlusion and habit patterns were not favorable for long-lasting results. Instead, tooth repositioning, bleaching, cosmetic contouring, and even composite resin bonding would have been a much more conservative and less invasive approach. Thus, we need to go “back to the basics,” where dedication to the functional analysis is first and esthetics is second to what the patient really needs.
A second concern of mine has been the lack of truth in advertising. I see so much hype in dental advertising implying that a great smile is quick and the benefits of cosmetic dentistry are amazing in only one day, when an alternate plan including orthodontics could be a much more conservative, less invasive, and long-lasting option.
There is a need to return to a more conservative approach for the patient, especially during these economically stressed times. For our profession to continue to thrive and maintain the trust of our patients, we need to always put the patient first and our own financial goals second. This is what my father taught me, and perhaps he knew it best because he started his practice in 1929, the year of the Great Depression. This is what I have tried to do during my 50+ years in dentistry and it is my hope that this will also be the legacy for which the dental profession will continue to strive.
It is a sad thing to acknowledge that the word “return,” as stated in this question, is valid. A conservative philosophy was the initial premise behind the protocols for esthetic dentistry brought forth in the early 1980s. The initial claims were that we wouldn’t need to prepare the teeth very much and we would fashion the impervious bond of our emerging esthetic materials to enamel.
What occurred next is something that frequently happens in a commercially driven society; a strong public demand fueled a meteoric rise in supply while the initial standards and proclamations were overlooked, or simply ignored. Consequently, tooth preparation became an afterthought to emotional marketing and decisions of commerce.
Need an example? How about the marketing phrase “instant orthodontics,” which was used in the early part of this decade to entice people to have their teeth prepared, sometimes very radically? Many patients took their dentist’s advice on this recommendation, as opposed to having their teeth orthodontically aligned to eliminate, or significantly reduce, the need for tooth preparation through the interdisciplinary synergy of orthodontics and restorative dentistry.
The question we must ask ourselves is, “why are we still needing to advocate this position?” It is time for all of us to work together in an interdisciplinary fashion to minimize the loss of healthy human tissue. We must utilize the discipline of orthodontics as an interdisciplinary adjunct to help make any dental treatment plan the most conservative it can be. Although the materials and techniques now available are amazing, there is absolutely nothing in our armamentarium that can come close to mimicking the structural characteristics of the dentin-enamel junction (DEJ). The DEJ is an amazing testament to biologic engineering that we simply cannot synthesize at this time. In essence, we need to give enamel the sacred respect that it deserves and there really needs to be a compelling reason to prepare beyond the DEJ of a healthy, previously unrestored tooth.
As we go through our daily treatment planning and restorative decisions, we owe it to our patients and our profession to keep all of our options in mind. With a united effort, we can “return to conservative esthetic dentistry.”
About the Authors
Elizabeth M. Bakeman, DDS
Dr. Bakeman is a clinical instructor at the Kois Center for Advanced Dental Education and has a private practice in Grand Rapids, Michigan.
Ronald E. Goldstein, DDS
Dr. Goldstein is a clinical professor of Oral Rehabilitation at the Medical College of Georgia School of Dentistry, Augusta, Georgia, and has a private practice in Atlanta, Georgia.
Michael R. Sesemann, DDS
Dr. Sesemann is the immediate past president of the American Academy of Cosmetic Dentistry and has a private practice in Omaha, Nebraska.