When Did the Line Blur?

by Stephen Zamon, DDS

About a year ago a new patient came to me for a second opinion. She had been to a “cosmetic” dentist and been given a treatment plan that left her confused and upset. Since her brother and his family have been my patients for years, I agreed to see her for a consultation.

Melissa was an attractive, intelligent 32 year-old in good health who worked in public relations. Her chief complaint was that she had some sensitivity on her posterior teeth and that she wanted to maintain her smile. Extra-oral examination was within normal limits and a smile analysis indeed revealed a very lovely appearance. Intra-oral examination showed normal tissue and periodontia with some occlusal wear and brown “spots” on the posterior teeth.

There was no collapse in her vertical dimension and the radiographs were within normal limits, except for a “thinning” of the enamel in some of the posteriors. There was no sensitivity to percussion or a cusp tester (Tooth Sleuth), but when I blew air there was a reaction on a few of the teeth.

The treatment plan that she had been presented with by the first dentist was to crown every tooth in her mouth; essentially do a full mouth rehabilitation. I immediately understood why she was so upset.

When I asked for the rationale behind this treatment plan, she told me that the dentist warned her of the dangers of grinding her posterior teeth into the “nerves”, the collapse of her face, and the destruction of her smile.

I asked Melissa if she was happy with her smile, and she quickly said yes. When I proposed eliminating her posterior sensitivity and removing the brown spots, and asked whether that would make her happy, she enthusiastically agreed.

I explained to her that, at some time in her life because of severe wear, it was possible that she might need extensive restorative dentistry to rebuild her mouth. I discussed the fact that, even if she went to the very best dentist in the world, a reasonable expectation of the life span of the crowns would be in the twenty to twenty-five year range. That meant that in her lifetime the crowns would likely have to be done at least three times.

Barring some discovery in the future that allows us to grow new virgin teeth, that is a considerable ordeal to inflict on her tooth structure. Taking the costs of treatment out of the equation, I asked her if she would be interested in delaying this extensive treatment for several years while still preserving her smile and comfort.

Melissa, of course, said yes.

My treatment plan consisted of fluoride applications, selective posterior composites, and a night guard. Her teeth were bright and did not need bleaching. Her sensitivity went away and, at this point in time, she is a happy young woman.

A second patient recently returned to me. She had left the practice two years ago because she had moved away. She told me that her new dentist used a “camera” on her teeth and demonstrated that she had several cavities. My records showed that while she was a patient in my office, her restorative needs were minimal. Intra-oral examination revealed some amalgam and composite restorations, and even with 3.2 loupe magnification, no obvious signs of caries. There were some areas of slight stain and wear around the restorations, neither of which concerned her. My treatment plan was to do nothing.

What is the point of these two seemingly disparate stories? I know that we have aggressive practitioners in our profession. I also know that if a patient goes to ten different dentists, they might very well get ten different but reasonable treatment plans. I accept that today there is a very strong interest in cosmetics in our society, whether it is the teeth, the face, or the body.

After practicing dentistry for thirty-six years, I find myself now asking, ‘when did the line blur?’ When did we move from a purely evidence-based scientific health profession to become purveyors of beauty parlour schlock with no science behind it?

Before my “cosmetic” colleagues vilify me, I will tell you that I do many cases of veneers and crowns and rehabilitation every year.

I do question, however, the “cosmetic” dentists’ desire to have their own specialty. “Cosmetic” work is simply part of an overall health plan for someone’s mouth. It is just good adhesive restorative dentistry. Periodontists act as “cosmetic” dentists when they sculpt the gingiva and bone with a crown lengthening. Orthodontists are “cosmetic” dentists when they create an ideal anterior guidance. Oral surgeons are “cosmetic” dentists when they move a jaw into a more pleasing profile.

All these specialties have proven scientific principles behind them: the periodontist maintains the biological width; the orthodontist utilizes the physiology of osteoclasts and osteoblasts in tooth movement; the oral surgeon corrects malocclusions by applying a thorough knowledge of facial anatomy. Frankly, if there is an argument for a new specialty, it should be geriatric dentistry.

Elderly people are the group who truly has special needs. The medications they are on frequently restrict salivary flow causing increased caries and periodontal disease. They often require specialized equipment and treating them is a difficult challenge requiring increased patience and psychological skills.

My concern is that when a patient is given a treatment plan from a purely “cosmetic” agenda, the consequences of their choices are often not explained. What is the longevity of the materials? What are the risks to more aggressive preparation of the teeth? Will they have to compromise in their choice of foods? When will the work have to be redone?

The advent of new technology is a two-edged sword. On one hand, a patient can be informed and educated. On the other hand, he or she can be frightened into treatment or sold a bill of goods. Anything can be made to look bad or in need of repair when magnified on a large screen.

The reason that a patient will accept your treatment plan and return to your office is not because of high-tech gizmos or specious promises of beauty. It is because of the trust that you build with them by looking in their eyes and presenting them a plan that is in their best overall oral health. Treat them like you would like to be treated.

The trust that you build with a patient is a very special thing. We must never abuse it.

When did the line blur?

Dr. Stephen Zamon is a Treatment Coordinator in the Comprehensive Care Program at the Faculty of Dentistry, University of Toronto. He also has a general dental practice with his daughter in Toronto.