Cosmetic Dentistry: Is It Really Health Care?

Now that the clinical limitations imposed by previous generations of restorative materials have been largely overcome, increased emphasis is being placed on the significance of esthetics in visible segments of the oral cavity. Dentistry, of necessity, has always been a profession dedicated to perfection; pursuit of the best possible biological result is a common goal among dentists. The best outcome of our endeavors includes the esthetic, or cosmetic, aspect of what we do. This artistic obligation in restorative dentistry is, along with the accompanying biological responsibilities, a given, a constant. Nevertheless, it now seems that a disproportionate emphasis is being placed on the cosmetic aspect of major restorations, even though ideal appearance has always been an integral aspect of restorative dentistry. Additionally, general practice may find itself at the brink of a fragmentation process if cosmetic dentistry should acquire sufficient momentum to lobby for its recognition as a specialty. Any such proposal would, of course, be absurd for two reasons: first, cosmetic dentistry clearly falls within the domain of general practice; second, we already have specialists in the field of major cosmetic rehabilitation — they are called prosthodontists. If this hypothesis regarding the future of cosmetic dentistry seems somewhat fanciful, you may wish to dismiss it. So be it, but there still remains a considerable basis for concern in that the vending of cosmetic rehabilitation to the public represents the very real possibility of over-treatment by exploiting human vanity and ignorance of dentistry and its less costly, more biologically acceptable alternatives. A further reason for consternation is the aggressive, overzealous business attitude that has appeared along with the heightened emphasis being placed on cosmetic dentistry.

One factor that has long been proposed as a contributor to the potential for overtreatment is the glut of dentists that exists in some parts of the country — a direct result of the lack of management of the local dentist-to-population ratio. In such a highly competitive environment, it becomes tempting to explore sources of revenue that may not be entirely ethical. As for the development of profit-obsessive attitudes toward the management aspect of dentistry, the popularity of both cosmetic dentistry courses and business management courses says much about the direction in which many dentists see themselves heading. It should be of dire concern to us that some lecturers handle both of these topics. Also, most of these “feel good” ambassadors who exhort Canadian dentists to increase fees on the basis of totally nebulous criteria are from south of the border.

Risking the possibility that I may be accused of being a pontificating dinosaur, I must express some dismay over the decline in concern for ethical judgment in the basic principles of practice management. This change obviously relates to an ideological generation gap between my age group and recent graduates. However, change is not necessarily progress, but beneficial change is. It is spurious indeed to imply that decreasing concern for ethics translates into beneficial change. What we now hear in presentations and read in some journals is that all dentists should raise their fees because of the astronomical salaries paid to sports stars and, also, because some U.S. conglomerates have found that increased prices can actually increase the demand for your product. In relation to sport — dentists are not necessarily undervalued; rather, the stars are grossly overpaid. In the manufacturing world, far less stringent ethical limitations exist for sales and advertising than exist in a health profession such as dentistry. A realistic audience would dismiss such examples as being irrelevant to the practice of dentistry. However, their message is clear and succinct — increase your fees because you’re darned good. The pure subjectivity of this scenario should be enough to convince the opponents of fee guidelines of the need for judicious controls of some kind.

It is not uncommon to see multiple porcelain veneers or crowns used on cases that are clearly orthodontic in nature. Practitioners may claim that the patient insisted on the option that they pursued, but when a case history is published and the issue of differential treatment planning is not clarified, readers are free to assume that the operator provided what he or she considered most appropriate. The insensitive clinicians who perform these unethical odontotomies on gullible, vain or misguided patients are wholly responsible for the course of treatment; patients are not. Dentists have the overall obligation to provide only the most appropriate treatment that is in the best interest of the patient. Failing to do so constitutes malpractice. Even the esthetic results of multiple veneers are not necessarily ideal. Formulization of dental esthetics negates human variation, resulting in “Chiclet” or “Steinway” dentitions. Individuality is suppressed by Hollywood standards of uniformity. Who could ever explain the inordinate success of such diastema-stricken individuals as Lauren Hutton, Robert Morse or the late Terry Thomas?

The historical danger in endorsing the recognition of cosmetic dentistry as a distinct facet of dentistry is that it may well diminish our significance as a true health profession. Although it typifies the combination of art and science that defines us, it clearly lies within the scope of general practitioners. If not performed in conjunction with the eradication or prevention of disease, it is of questionable health value to the public — cosmetic make-over at best, and shameless exploitation of public ignorance at worst. Ethical odontotomy guidelines may now need to be formulated. Those who, ahistorically, see us as a cosmetic service industry will eventually preside over our decline from doctors to mere clinical technicians. Some will stress the psychology of a vivacious smile — but there again we might be walking on marshy ground — a whole new world of “psychodontics” waiting to be explored… and perhaps exploited.

Dr. Mulcahy is a 1967 graduate from the University of Toronto, now retired in Edmonton, Alta.