Great expectations?

Cosmetic dentistry is a rapidly expanding industry with an estimated £1.5 billion spent each year in the UK alone.

However, according to MDDUS dental adviser, Doug Hamilton, while provision of cosmetic treatment can be a hugely satisfying aspect of dentistry, managing the expectations of patients, who may be searching for the perfect smile, can present unique challenges.

He says: ‘Cosmetic procedures are such a big part of dentistry nowadays, it is inevitable practitioners will at some point encounter patients who wish to electively alter their smile.’

‘This type of treatment, if properly planned and executed, will undoubtedly bring much happiness to the patient. However, it does carry with it practical difficulties which are perhaps not so commonly encountered in therapeutic interventions.

‘Even when essential treatment goes wrong, complaints often follow. However, if the patient’s perception is that the work “isn’t what I expected” or “wasn’t necessary”, the complaint tends to be that bit stronger.’

Many of the techniques used in cosmetic dentistry treatments may look quite straightforward but, in reality, are hugely ‘technique sensitive’.

Doug says: ‘For the less experienced operator to attempt complex cases before mastering the basics, the result can be calamitous. Therefore, it is critical to recognise and work within your scope of competence.

‘In fact, before any treatment is undertaken, a proper examination is essential. The next stage is to provide all the clinical information that a reasonable patient would require to know.

‘This includes advice regarding risks. In cases involving elective treatment, however, there may be little or no risk associated with non-intervention (apart from patient disappointment). This point must be explained in understandable terms long before treatment commences.’

At first glance, external bleaching, which appears to be simple and non-invasive and therefore unlikely to result in any lasting harm, might seem to require less in the way of pre-operative warnings.

However, he advises against any such complacency.

He explains: ‘Aside from the new bleaching legislation which should be scrupulously observed, there are practical concerns such as costs, peri-operative sensitivity and the non-bleaching of restorations.

‘The patient may also need to be advised of alternative means by which teeth can be made to appear whiter, like polishing, smoking cessation or internal bleaching for non-vital teeth.

‘In fact, virtually every procedure, however innocuous, cannot commence until valid consent has been secured. This consenting process must include provision of a written cost estimate. Elective treatment will likely be relatively expensive and with higher bills come higher expectations.

‘Therefore, it is vitally important to provide patients with an accurate idea of what is achievable. This could be done through accessible and honest communication, written and verbal, combined with teaching aids such as pre- and post-operative photographs of similar cases. It’s important to be realistic, regardless of the patient’s enthusiasm for an enhanced smile.

‘The obvious problem is that judgement of what constitutes an enhanced smile can be highly subjective. Cosmetic outcomes are not as easy to define which means that there will always be situations where the operator is delighted with the result but the patient is dissatisfied.’

Avoiding this highly frustrating scenario is usually a product of years of patient assessment and management.

But, he adds: ‘However, even the most experienced practitioner can be caught out. Being confronted with the realisation that your patient’s expectations are actually unrealisable or simply indefinable is not pleasant. The trick in these situations is to know when to quit.

‘Replacing already excellent restorations is rarely helpful. At best, it fuels the patient’s delusions. At worst it leads to fractures, symptoms and general bad news. Assuming that the patient has not been misled in the first instance, an empathetic yet firm withdrawal from the case may prove to be the least worst option.

‘Finally, remember the old adage, “if it’s not in the notes, it didn’t happen”.

‘Recording details of examinations, radiographs, consenting, treatment progress etc, can be tiresome and time consuming. However, good record keeping is expressly required by the GDC and, if something goes awry, these notes can save you a lot of unnecessary stress.’

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