Are cosmetic procedures being overprescribed?

2009 12 03 14 54 58 936 Smile 70

The perfect Hollywood smile is in high demand these days. But is this trend prompting dentists to overprescribe cosmetic procedures? Recent news reports have raised concerns that patients feel pushed into cosmetic procedures during routine visits.

"Cosmetic dentistry has been very popular for the past few years, and some bad apples may be overprescribing," said Hugh Flax, DDS, the president of the American Academy of Cosmetic Dentistry (AACD) and a cosmetic dentist in private practice in Atlanta.

Dr. Flax believes that it is important to ask patients what they are looking for during the initial interview and get a sense of their long-term goal and if cosmetic dentistry is a part of it.

While making patients aware of procedures that may have aesthetic benefits for them is a good idea in today's world, the focus should be on "responsible procedures," he added. "The dentists' foremost focus should be on making the patient healthy."

However, it's always possible to improve someone's smile while he or she is getting dental work done, Dr. Flax said.

"Say a patient comes in with decay around silver fillings," he said. "You can clean up the decay and put tooth-colored materials in there for better aesthetic results. Responsible aesthetics is about making them look better and making them healthy."

The ethics of aesthetics

While it is legitimate for clinicians to inform patients about procedures that they may be unaware of and which could be of use to them, it is important to present the procedures as options, without any arm-twisting or bias, according to Rosamond Rhodes, PhD, a professor of bioethics at the Mount Sinai School of Medicine.

"A person could have been walking around with yellow teeth, not knowing that something could be done about it," she said. "It's permissible [to tell the patient about cosmetic improvements], but it is important for the clinician to be responsible about it."

“Some patients may
find veneers and whitening unnecessary, while others might find them vital.”
— Matthew Messina, DDS

Ethically, when dentists do a general exam and see a malocclusion, they can recommend orthodontic treatment so the patient can regain confidence and his or her smile, said Bennett Tochukwu Amaechi, BDS, an associate professor at the University of Texas Health Science Center at San Antonio.

"Many people are not dentally aware and may not know that this problem can be fixed," he added.

But he recommends using caution when offering cosmetic procedures.

"If you see a patient who has stained teeth, it may be lowering their confidence and you can advise them to go for a teeth whitening," Dr. Amaechi said. But if the teeth are healthy with a good natural color and the dentist starts recommending whitening, "that's a problem," he said.

According to Matthew Messina, DDS, ADA consumer advisor, there is a fine line between educating a patient and pushing a procedure.

"Everything in dentistry is more aesthetic than before," he said.

TV shows such as "Extreme Makeover" have started a trend, and patients get their cues from such public venues as much as they get them from the dental office, Dr. Messina added.

Like Dr. Flax, he said the key is to understand what the patient's true needs are. He suggests presenting treatment options in the form of "must do," "should do," and "can do." For example, taking care of decay and pain is a "must do," while long-term care -- such as a crown -- is a "should do." Whitening and veneers qualify as a "can do."

"Some patients may find veneers and whitening unnecessary, while others might find them vital," Dr. Messina said.

Profits vs. responsibility

One reason procedures that have the cosmetic label attached to them can fall into the "can do" category is that insurance may not necessarily cover them.

A procedure not covered by insurance can be very lucrative for a clinician, and clinicians have a responsibility to put patients before themselves in these circumstances, Rhodes said.

"There will often be a conflict between what is good for you and what is good for the patient," she said. "When money gets involved, it can distort judgment and cause bias."

Clinicians should always try to present a fair picture of costs and the effectiveness of procedures. Patients do not like surprises, Dr. Flax and Dr. Messina both emphasized. If insurance may not cover a procedure, it is important to make it clear before starting treatment.

"If a patient is surprised by the fee of a procedure or the fact that insurance will not cover it, no one is happy -- not the practice, not the patient," Dr. Messina said. "You don't want a patient to get buyer's remorse, especially with irreversible procedures."

And just because insurance does not cover a procedure doesn't mean it is unnecessary, he added. Many procedures come with the cosmetic label but offer oral benefits.

For example, "orthodontics has tremendous functional benefit, but most adults go for it for aesthetic purposes," he said. Orthodontic treatment can lead to fewer crowded teeth, which are easier to clean; improves hygiene; and lowers the risk of periodontal disease. In addition, anterior crown and bridge work can lead to a better bite and function.

However, for procedures that have both functional and cosmetic benefits, different dental practices may offer different treatment plans with varying price tags. Dr. Flax chalks up these variations to different levels of training and experience. In addition, variations in treatment plans also take into account the patient's goals.

It is important to understand if the patient wants to spread out the treatment plan or needs more urgent care for an upcoming event, such as a wedding, he said.

"Treatment plans depend on the temperament, goals, time, and budget of the patient, as well as what the dentist is capable of achieving," Dr. Flax said.

Opportunities and education

It is also important to recommend aesthetic procedures to patients as opportunities and not to make the patients feel defective. For example, if you are recommending whitening, don't start with "Your teeth are really yellow," Dr. Messina said.

Another approach is to include a smile analysis in new patients' and returning patients' exams. Most questions in the dental practice focus on pain and infection, but you can add questions about smile, he explained.

If the patient expresses a need for a whiter or straighter smile, that is an opportunity for a dentist to provide information on whitening, Dr. Messina said. A dental office can also display before and after photos of procedures, which can lead to patient inquiries.

The focus should be on patient education and communication, according to Roger P. Levin, DDS, chairman and CEO of the Levin Group, a dental consulting firm. "Let the patient know of services available in the practice," he said.

For example, during the dental exam, hygienists can identify any elective procedures the patient can benefit from -- be it whitening, laminate veneers, or replacing silver fillings with composites, Dr. Levin said. He also recommends the following:

  • Send quarterly e-mails with updates on new services offered at the practice.
  • Use visual aids such as procedure videos, models, and before and after pictures of procedures.
  • Using mock-ups, take a composite and apply it to a model to give patients an idea of what they may look like after the procedure.

"We counsel our clients to provide outstanding customer services so patients are aware of all services and can make educated choices," Dr. Levin said. "It is not about selling procedures, but about patient education."

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