Cosmetic dentistry is an increasingly popular undertaking for many dental practitioners but is laced with dentolegal risks. Dr Martin Foster, Dentolegal Consultant at Dental Protection, talks through the principal learning points.

It is worth remembering that ever since the earliest days of dentistry patients have sought help with two main issues. The treatment of disease and the improvement of appearance, and not necessarily in that order. 

In providing care it is obviously important to ensure patient needs are met and there is shared approach to clinical decision making. This can be tricky if patient wants and expectations are at odds with what is actually required to achieve an improvement in terms of oral health.

One of the biggest ethical challenges in providing dental treatment that is elective and ‘wants based’ rather than strictly ‘needs based’ is the necessity to ensure that any intervention proposed will do no harm. 

A thorough case assessment

The key factors to take into account in meeting this challenge are firstly ensuring that there is a very careful and thorough case assessment so that there is a very clear record of the starting point. Patients often have selective memory. Once treatment is underway, they can all too easily forget what the initial position was.

To ensure that there is a complete understanding of the whole picture, the case assessment should take account of the various patient factors, such as history, motivations, expectations and the goals the patient hopes the treatment will achieve. In addition, the full range of occlusal, biological and structural factors that form the clinical environment against which any treatment will be carried out, and the existing smile and facial characteristics, need to be taken into account as these will clearly influence the outcomes which are possible.  

As with treating disease, treatment that is primarily intended to improve aesthetics must be based upon a correct diagnosis of what the issue is, if the appropriate options to achieve success are to be correctly identified.

Once treatment options have been identified it is of critical importance that the patient receives comprehensive information and clear explanations detailing the comparative advantages, disadvantages and costings of each option. It must also be emphasised in all cases where cosmetic treatment is being considered that “no treatment” is always the first option. 

In terms of fulfilling the primary ethical duty of doing no harm, whenever there is no disease to address, there is inevitably going to be an inherent risk of doing more harm than good when any intervention is undertaken. 

On the subject of risk, it should go without saying that a clinician should not embark upon any procedure unless they have the skills and competence to see it through successfully. It may be worth reflecting on the reality that elective procedures are not about fixing damage but are actually about trying not to damage something that is not broken. You do need to be sure you can do this. If in doubt an onward referral or second opinion may be the best favour you can do your patient and yourself. 

Managing expectations

It is clear that social media has played an increasingly influential role in the promotion of dental services to patients. In the same way it can also be used very effectively to manage the expectations of patients with regards to cosmetic treatments. If there is any reluctance among colleagues then it may be helpful to have a conversation with them about why they are reluctant – it might be that they haven’t grasped the benefits, or there is a bit of a fear of the unknown – or perhaps they have had previous negative experiences.

Building a social media presence for your practice can be an important tool for you to promote your services and attract new patients, while also strengthening relationships with existing patients – and using these channels to post before and after pictures can be a helpful way to validate any claims made about your competency in cosmetic procedures.

However, you must be careful about what you promise; don’t raise unrealistic expectations by showing pictures of perfection. If they are your own examples, get the patient’s consent – but if they are stock photos then you must be clear about this.
  
Cosmetic treatment involves what is going on in the patient’s head as well as managing the operative clinical aspects. It is therefore necessary to understand where the patient is coming from. A experienced dentist should be able to carry out an intra-oral and extra-oral assessment effectively but it can take a fair bit of additional effort to get inside a patient’s thought processes and understand where they are coming from in terms of what they see as the problem, and what a successful outcome will look like – for them.  It is only when you understand the problem from the patient’s perspective that you will be able to consider what solutions, if any, can be offered. 

You may feel that the problem is obvious but remember you are seeing the situation as a dentist. A dentist will understandably default to dentist solutions and you may be tempted to suggest a way forward that will not in fact address the patient’s problem. So in terms of diagnosis, it is important to spend time actively listening to what the patient is really saying. Assume nothing; ask questions – what are their goals for their teeth/mouth/smile? What will success look like? 

Are there any alarm bells ringing for you? If the patient expresses the view that once they have the work done they will get that job/partner/career/success in life that they should have, you may need to think twice about embarking on treatment. You may be able to effect some cosmetic improvement but revolutionising someone’s existence is probably not an achievable treatment aim.

The patient may have their own ideas of what the optimum treatment plan is and what the outcome should be, and it is critically important to ensure that this is in alignment with reality. The important fact to bear in mind with any sort of cosmetic treatment is that even the most technically excellent result can give rise to dissatisfaction if it does not match the patient’s perception of what success should look like. If there is any doubt as to what is expected or whether or not you can reach the end result the patient is expecting, it is advisable not to set out on that journey.

A treating clinician has the advantage of understanding the whole process and what is achievable. The duty exists to ensure the patient shares this understanding whatever the treatment provided, and this is all the more so for elective procedures.

No surprises: taking consent

It can be helpful to think of the consent process as a means of avoiding surprises. When obtaining consent for cosmetic treatment it is worth bearing in mind that patients seeking such treatment are motivated by the primary sensory input of vision. It is all about appearance after all so it makes sense to use visual aids, images, models, videos, before and after photos and illustrated information to get the message across. 

Remember also that your patients are real human beings, not computer-generated images, so it is wise to use realistic photos of what can actually be expected rather than images of impossibly perfect teeth radiating from beautifully photogenic faces. And yes, you can use clinical images from your own cases for patient education purposes but you should anonymise these and get the patient’s permission.              

Having provided the patient with all the information at your disposal you need to check they have retained and understood this. As well as a firm grasp of the treatment itself, the patient should be under no illusions about the fees and the timeframe. It is vitally important that the patient has no unanswered questions so say: 

• Does that make sense? 
• Would you like more information on this?
• There is a lot to consider, I hope that I have explained this clearly.
• Please do let me know if you have any questions.

We know that people process information in different ways. Providing the patient with a detailed written, no-jargon description of what been discussed can be hugely helpful for a number of reasons.  

Firstly, it allows the patient to have ready access to the details of the proposed treatment and also allows them to refresh their memory of the discussion and explanations provided. As well as this, there will then be a dated, clear statement of the information provided as a useful addition to the record of the patient journey. Importantly it can serve as supporting evidence of a consent process being followed.

Given that many cosmetic procedures are elective, there is generally no clinical urgency. Although there may be a patient-generated impatience to get started it is advisable to allow a cooling off period to allow the patient to reflect and confirm that they are in fact happy to proceed. Although more of a time commitment, it can be a good investment to give patients the opportunity to have a second consultation if they wish.   

It should be too obvious to state but treatment should not start until you are satisfied that both you and the patient are on the same page in terms of where you are headed, how you are going to get there, how long it will take and what it will cost.

If ever there was a situation to apply the old maxim “make haste slowly”, embarking upon cosmetic treatment is definitely an example. Investing time and effort in careful clinical assessment, identifying the patient’s wish list, exploring the options and developing a plan that both sides understand and agree is time-consuming. On the other hand, taking shortcuts with any of these will likely be a false economy and will cost more in time, effort and potential disappointment in the long run.

Problems arise when not enough time is given to clear communication at the outset so before reclining the chair and working on what is in the patient’s mouth, take the time to draw up a chair and work on what is going on in the patient’s head. Above all, remember “first do no harm”.  If there is a risk of more harm than good then ethical sense should prevail over aesthetic sensitivities.

In summary 

Overall, when considering what treatment to offer you should be realistic: under-promise and over-deliver. It’s important the patient knows what is realistic – manage their expectations: you can get patients with body dysmorphia who think fixing their teeth will improve their body image. 

Make sure the treatment is appropriate and justifiable; don’t let patients push you into inappropriate treatment. Consent and record-keeping for elective procedures should be robust, and alternative options should always be offered, including doing nothing at all. Remember to discuss the risks and benefits, including the longevity of the restoration and likely length of treatment.


To view a recording of Dental Protection’s webinar on Cosmetic Dentistry, log in to your PRISM e-learning account.