The cost of perfection

IT IS estimated that over £1 billion is spent each year on cosmetic dentistry in the UK. Therefore, it is likely that, sooner or later, members will encounter patients who wish to have elective treatment in the hope that their smile can be enhanced.

Cosmetic treatment, if properly planned and executed, can produce significant benefits, not least in terms of the patient’s self-esteem. Therefore, quite correctly, this sub-speciality is an established and highly regarded facet of dental practice. However, this particular field also presents potential difficulties which are perhaps less commonly encountered in therapeutic interventions.

Take, for example, a complaint against one of our members who had placed crowns in order to save his patient’s fractured, carious incisors. The final restorations were well fitting and aesthetically pleasing. However, one of the prepared teeth subsequently became acutely painful and required endodontic treatment.

At this point the patient initiated a formal complaint. Our member was genuinely sorry that these complications had occurred but explained in his response (with reference to his excellent records) that all material risks, including the risk of pulpitis, had been discussed pre-operatively. The patient was also reminded that these crowns had been essential if the patient was to retain his front teeth. These reassurances were accepted by the patient and the matter was resolved amicably.

What if the crown provision had been elective? Perhaps the patient’s incisors had been sound but unsightly. Therefore, the treatment had been driven by a desire for a 'perfect smile' rather than clinical necessity. Would our member have been more vulnerable if one of the prepared teeth became symptomatic? Again, the practitioner may have felt that he was in a strong position, assuming the elective crowns had been properly consented, well-documented and of good quality. However, it seems reasonable to suggest that, in comparison to the first scenario, the risk of conflict is heightened. In other words, patients tend to be more fractious where the work "didn’t need to be done in the first place".

Therefore, we might conclude that particular risk-management measures should be considered when non-therapeutic treatment is being considered.

WALK BEFORE YOU RUN

All operators should reflect carefully on their skill set before embarking upon aesthetic cases. However, this advice is, perhaps, more applicable to recent graduates. Many of the techniques outlined in publications look impressively straightforward but are actually highly technique sensitive. Attempting complex cases before mastering the basics can lead to all sorts of calamities, so it is critical to recognise and work within your scope of competence.

Experience also tends to enhance the practitioner’s ability to assess the cases from a patient-management, as well as a clinical perspective. As we learn to listen to even the most distant warning bells, it becomes more likely that certain challenging patients and/or high-risk procedures will be politely declined. Sometimes, the disappointed patient decides to ‘dentist-shop’ for a more malleable practitioner. It is often younger colleagues who end up being pressurised into undertaking ill-conceived or overly ambitious treatments. Patient-led dentistry is a recipe for disaster. It is the clinician who considers which options are justifiable and presents them (along with suitable information). Then it is the turn of the properly informed patient to decide whether to give or withhold consent (not the other way round).

Although this rule is axiomatic, there are circumstances where the patient may, quite understandably, feel aggrieved when the expected treatment is refused. Special deals, for example, might seem like a commercially astute ploy. The danger is that this approach can appear to guarantee certain treatments to patients (at a competitive price). Once the clinical assessment has been completed, it may be discovered that this is not a suitable case. Disappointment, not to say indignation, is sure to follow. Even so, it is vital that you do not take on cases that are contrary to your clinical judgment, irrespective of the patient’s determination to take advantage of their discount voucher.

CLEAR INFORMATION

Following an appropriate pre-operative assessment, the operator must provide all the clinical information that a reasonable patient would require to know. Ultimately, patients should be given a treatment plan/cost estimate for their consideration and signature. However, before this plan is finalised there must be a description of the proposed treatment and of alternative management (which incorporates the ever-present options of non-intervention and delayed intervention). This explanation should be accompanied by advice regarding the material risks associated with each option.

When considering therapeutic treatment, there may well be a risk associated with both active and passive management. Returning to the earlier example where jacket crowns were needed to restore vital but compromised incisors, it seems to be accepted wisdom that this treatment will carry about a 10-20 per cent chance of the pulp becoming moribund. A patient may withhold consent on this basis, but should do so only after being advised as to whether failure to crown may result in other problems such as the teeth eventually becoming un-restorable.

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.

Of course, if the patient continues to request treatment, the dentist will usually attempt to achieve the desired result, using the approach that carries the least risk. For example, in cases involving discoloured yet intact anteriors, the dentist may discount the options of crowns (or veneers) and recommend external bleaching. At first glance this non-invasive treatment is unlikely to result in any lasting harm. Therefore, one might be forgiven for truncating the standard consenting discussion.

In fact, there are often practical concerns (aside from regulatory restrictions) such as costs, peri-operative sensitivity and the non-bleaching of restorations. Patients must be aware of such material risks before treatment commences.

MANAGING EXPECTATIONS

Therefore, we have established that even the most conservative cosmetic procedure must be preceded by an appropriate consenting discussion. As stated previously, this process usually culminates in the production of a written cost estimate. In all likelihood, elective treatment will be relatively expensive and with higher bills come higher expectations. It is therefore vitally important to provide patients with an accurate idea of what is achievable. This could be done through accessible and interactive communication, 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. Where, for example, a patient presents with an acute pulpitis, provision of pain relief is generally the mutually expected end-point. Cosmetic outcomes are less easy to define, which means that, even with the most comprehensive and transparent consenting process followed by technically excellent treatment, 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 (plus some luck). 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 unrealistic hopes. At worst it leads to fractures, symptoms and general bad news. Assuming that further interventions would not have a credible prospect of addressing the patient’s unhappiness, an empathetic yet firm withdrawal from the case may prove to be the least worst option.

(BROKEN) RECORDS

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, but it is extremely important. If something goes awry, these notes can save you a lot of unnecessary stress.

Doug Hamilton is a dental adviser at MDDUS