The cost of perfection

IT is estimated that up to £1.5 billion is spent each year on cosmetic dentistry in the UK. So, regardless of where graduates choose to start practising, it is likely that they will soon 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.

Take, for example, a recent 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. In keeping with my theory that Sod’s law is the governing principle in dentistry, the accessed preparation then fractured (over Christmas).

At this point the patient initiated a formal complaint and threatened to seek the advice of a solicitor. Fortunately, the high standard of our member’s work was also evident in his record keeping and we were able to assist with the production of a strong defence. Once the complaint had been resolved, our member reflected on how stressful the entire episode had been. He had felt genuinely sorry that these complications had occurred but was at least reassured by the fact that crowns had been essential for the patient to retain his front teeth.

Meeting expectations

What, then, if the crown provision had been elective? Perhaps the patient’s incisors had been sound but slightly imbricated or discoloured and the treatment had been driven by a wish for a more ‘perfect smile’ rather than necessity. Would our member have been more vulnerable to a claim when one of the prepared teeth became symptomatic and fractured? In fact, the law does not necessarily demand higher standards for non-therapeutic treatment. Therefore, if the crowns were clinically justifiable, properly consented, well-documented and of good quality, the practitioner might well have a strong defence.

Unfortunately, such niceties tend to be lost on unhappy patients. Even when essential treatment goes wrong, complaints often follow. However, if the patient’s perception is that the work “didn’t need to be done in the first place” or that the dentist “was out to make money” or that the result “isn’t what I expected”, the complaint tends to be that bit more piquant.

Here are some practical tips for avoiding these scenarios:

Firstly, learn to walk before you run. 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.

In fact, experience will often enhance a practitioner’s risk management skills as well as clinical abilities. As we learn to listen to even the most distant warning bells, it becomes increasingly likely that certain ‘high-risk’ patients or procedures will be politely declined. The disappointed patient may accept this wisdom or may look for a more malleable practitioner. In the latter case, younger colleagues can end up being pressurised into undertaking ill-conceived or overly ambitious treatments. This is a recipe for disaster. It is the clinician who considers which options are justifiable and presents them to the patient who then decides whether to give or withhold consent.

Even though this rule is axiomatic, there are circumstances where the patient may, quite rightly, feel aggrieved when the expected treatment is refused. Special deals, for example, might seem like a commercially astute ploy. However, this approach may appear to guarantee treatment to patients which cannot be offered once their dental health has been assessed. Remember, when it comes to marketing, there is a fine line between the persuasive and the unethical.

Clear information

To avoid any difficulties, a proper examination is essential before a treatment plan is formulated. The next stage is to provide all the clinical information that a reasonable patient would require to know. This includes advice regarding risks, not only associated with undergoing the suggested treatment, but also of declining. Thus, where jacket crowns are needed to restore fractured incisors, this treatment carries 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 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.

Another treatment to consider carefully is external bleaching. At first glance it appears to be simple and non-invasive and therefore unlikely to result in any lasting harm (unless the super-bleached smile brings down aircraft). Surely, very little in the way of pre-operative warnings and general consenting is needed for this treatment?

In fact, 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 (or perhaps getting a spray tan).

Managing expectations

Virtually every procedure, however innocuous, requires consent, a process that must also include 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 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. 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. 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, if something goes awry, these notes can save you a lot of unnecessary stress.

Doug Hamilton is a dental adviser at MDDUS