Imagine you are 18 years old and all your life you have dreamed of a career in acting or modelling. Everyone that you talk to in your chosen field tells you the same thing. You have what it takes to make it, except for one thing. Your teeth are simply too unattractive. So you do the logical thing. You consult your family dentist, the only dentist you have ever known. Your dentist tells you that modifying your teeth purely for cosmetic reasons would not be ethical and she cannot help you. You are clearly devastated as you see your career aspirations slip away. This scenario is still all too common. Aesthetic dentistry has an image problem in some corners of our profession. It’s ironic that a discipline that is responsible for improving the image of so many people should have image issues of its own, especially within the profession.
Perhaps we should start with a discussion of terminology. We can’t even seem to decide what to call the field of appearance-related dentistry. Is it cosmetic, or aesthetic? For that matter, is it aesthetic or aesthetic? We are not alone. Our medical colleagues wrestle with similar questions.2,9,11 Historically aesthetic dentistry was considered to be that branch of dentistry that seeks to make our restorative dentistry blend in with the existing dentition while cosmetic dentistry was done purely for appearance without regard for function or longevity, although this probably had more to do with the durability of the available techniques and materials of the day than the treatment goals of the profession.10 Webster’s definition of cosmetic includes terms such as decorative, ornamental, not substantive, and superficial. Aesthetics is the study of beauty and goes beyond mere appearance. Beauty is the marriage of aesthetics and taste, and in a dental context certainly needs to include the added criteria of function, comfort, and durability. Given these definitions, we can probably agree that aesthetic is the more suitable term for what we do, and aesthetic is merely an accepted variation in spelling.
So where does the perception that aesthetic dentistry is not valuable come from? We can all agree that appearance while important, is not the most important human attribute. Appearance takes a back seat to our values, our character, our actions, our desires to improve the world. Still it is entirely reasonable that we feel the need to look our best. The value of a pleasing appearance is well documented.6 And patients who wish to improve their dental appearance deserve to have it done by a thoroughly trained and qualified dentist.
Zografos explored the effects of social media on the perception of beauty and its effect on the demand for aesthetic dental treatment, concluding that social media is fuelling public demand for “impossibly perfect” teeth and that aesthetic treatment “may not be necessary” and represents ”significant clinical and other risks”.12 The author further implies that aesthetic dentistry has a negative effect on patients’ health and suggests that such treatment is therefore unprofessional. These accusations are misplaced and highly concerning. As an example, the article references a case in the UK where a 17 year old patient was treated with four anterior veneers despite poor oral hygiene, caries, and unrestorable teeth which ultimately resulted in the loss of the treated teeth. Even though the treatment plan was probably inappropriate, there is no reason the veneers, if properly done, would have caused those teeth to deteriorate any faster than the rest of the dentition.1,4,5,7,8 Clearly the treatment was poorly planned and even more poorly executed. That is a reflection on the practitioner, not on aesthetic dentistry in general. To suggest that these complications are a natural consequence of aesthetic dentistry is absurd and insulting. If dentistry has played a role in creating “impossibly perfect teeth” as a standard of beauty, it is because we so often achieve results that seem impossible. The technology exists to perform exquisitely beautiful restorative dentistry that is minimally invasive and extraordinarily durable, and when done properly complications are extremely rare.
It is true there is far too much aesthetic dentistry that is poorly done or inappropriately treatment planned, but it is absurd to suggest that this is a problem inherent in aesthetic dentistry. Let’s face it. Dentistry has become a challenging way to make a living. We have too many dentists competing for a limited number of patients. Combined with the fact that our profession has been spectacularly effective from an epidemiological perspective, doctors who graduate with crippling levels of debt, manufacturers who perpetuate the myth that dentistry should be fast and easy, governments that feel the need to impose ever increasing restrictions on businesses of all stripes, and you have a recipe for dentists performing advanced treatment they may be underqualified for. The temptation to put one’s own economic survival ahead of the patient’s best interests must be overwhelming for some. Unfortunately aesthetic treatment seems to be the low hanging fruit for those seeking to increase their workload because the indications for treatment can be somewhat subjective, there is no mechanism for the public to determine who has the appropriate training to perform aesthetic dentistry well, and there are few broadly accepted standards for assessing what constitutes quality treatment. Blaming aesthetic dentistry for the demographic and economic problems facing our profession serves no one’s interests.
It would appear that the Dunning-Kruger effect is at work here.3 In short, we don’t know what we don’t know. No one with adequate advanced training in aesthetic dental treatment doubts its value. When you lack training and experience in aesthetic dentistry and you see bad case after bad case, it must be easy to conclude that aesthetic dentistry itself is at fault and that we should actively discourage any dental procedure designed to enhance a person’s appearance. The truth is the fault lies with inadequate education. We do not graduate from dental school with the necessary skills to perform complex dental treatment. Quality aesthetic treatment is incredibly complicated, requiring the coordination of multiple dental specialties, extensive knowledge of dental materials not to mention the technical skills to direct the technician in their selection and use, advanced patient management skills including the ability to recognize relevant personality disorders, and a myriad of other skills, many unique to the discipline. And this is before even picking up a handpiece. A weekend course is simply not going to bridge that gap.
The body of knowledge in the field of aesthetic dentistry is arguably comparable to any of the specialty disciplines, yet as a profession we are failing to properly manage that body of knowledge. While there are a number of fine organizations dedicated to the promotion of excellence in aesthetic dental treatment, if post-graduate education is to be meaningful it must occur at the university level. There have been a number of excellent post-graduate education programs started over the years, but most have failed for lack of support by the profession at all levels. The Postgraduate Program in Aesthetic Dentistry at SUNY Buffalo was an excellent residency program and a pioneer in aesthetic dentistry education before it fell victim to anti-aesthetic bias. University of Minnesota also had an outstanding program before it too was terminated. Unfortunately these programs have all too often been seen as a cash-cow for the educational institutions that sponsor them. If they cannot turn a profit, and sometimes even if they do, they are not considered useful and are easily terminated. This is not in the best interests of the public.
It is a self-fulfilling prophecy. We conceitedly view aesthetic dentistry as inconsistent with our desired self image as health care professionals. Some argue that aesthetics is not a valid field of study because personal preference plays a role, and this makes success difficult to quantify. For these reasons and others, we do not develop adequate educational programs at the university level, which results in a dearth of dentists properly qualified to perform aesthetic treatment. This of course results in treatment that is poorly done, which only serves to reinforce the perception that aesthetic treatment is bad treatment. And around we go.
The solution should be obvious. Aesthetic dentistry must be recognized and valued by our profession. There needs to be significant post-graduate education available from our dental schools, along with the establishment and recognition of acceptable standards of aesthetic treatment at the educational and regulatory level. There needs to be education of dental technicians in proper aesthetic dental techniques, which will only occur when there is appropriate guidance from the dental profession. And finally there needs to be widespread acceptance of the fact that significant advanced training is required to perform aesthetic dentistry well.
It is time for aesthetics to take its rightful place as a worthy field of study within dentistry. If we as dentists don’t do it, who will? We must demand the same standard of care from dentists performing aesthetic treatment that we demand from every other field of study within dentistry.
Oral Health welcomes this original article.
References
- Alenezi A, Alsweed M, Alsidrani S, Chrcanovic B. Long-Term Survival and Complication Rates of Porcelain Laminate Veneers in Clinical Studies: A Systematic Review. J Clin Med 10(5):1074, Mar 2021.
- Brown T. Cosmetic or Aesthetic – letter to the editor. Aesth Surg J 36(4):163-64, 2016.
- Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psych 77(6):1121-34, Dec 1999.
- Layton D, Walton T. An up to 16-year prospective of 304 porcelain veneers. Int J Prosth 20(4):389-96, Jul-Aug 2007.
- Layton D, Walton T. The up to 21-year clinical outcome and survival of feldspathic porcelain veneers: accounting for clustering. Int J Prosth 25(6):604-12, Nov-Dec 2012.
- Little AC, Roberts CS. Evolution, appearance, and occupational success. Evol Psychol 10(5):782-801, 2012.
- Morimoto S, Albanesi R, Sesma N, Agra C, Braga M. Main Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers: A Systematic Review and Meta-Analysis of Survival and Complication Rates. Int J Prosth 29(1):38-49, Jan-Feb 2016.
- Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. Porcelain veneers: a review of the literature. J Dent 28(3):163-77, Mar 2000.
- Tansley P,Hodgkinson D, Brown T. Comments on “Defining Plastic, Reconstructive, Aesthetic and Cosmetic Surgeries: What Can Get Lost and Found in Translation”. Ann Plast Surg 86(4):487-488, Apr 2021.
- Touyz L.Z., Raviv E., & Harel-Raviv M. Cosmetic or esthetic dentistry. Quint. Int 30(4):227-33, Apr 1999.
- Wei X, Gu B, Li Q. Defining Plastic, Reconstructive, Aesthetic and Cosmetic Surgeries: What Can Get Lost and Found in Translation. Ann Plast Surg 83(6):609-610, Dec 2019.
- Zografos C. Say cheese: How pervasive ideals of dental perfection within media have influenced dentistry. J Ont Dent Assoc 98(4):26-30, May 2021.
About the Author
Dr. Bill Turner is a general dentist in Thunder Bay, Ontario with an interest in esthetics. In addition to his dental degree earned at the University of Manitoba in 1981, he holds a Certificate of Proficiency in Esthetic Dentistry from SUNY Buffalo, and is a Diplomate of the American Board of Aesthetic Dentistry. He holds fellowships in The Academy of General Dentistry, the American Society of Dental Aesthetics, the Academy of Dentistry International, and the International Academy for Dental Facial Esthetics. He has contributed numerous articles about esthetic dentistry to this and other journals, as well as authoring the chapter on fiber-reinforced composite bridges in Freedman‘s ‘Contemporary Esthetic Dentistry’. He is currently enjoying retirement.
