Chapter 24- Non-destructive Cosmetics.

One of the concepts in medicine is that the patient should be better off when you have treated them than before you started or at least no worse off.

The mantra is ‘do no harm’.

‘Cosmetic’ as an adjective is used to refer to substances or treatments that are intended to improve the appearance of something without changing its basic structure.

Now obviously there is a place for everything and everything in its place.

If you had a nose that was 3’ long or thighs that were bigger than your waist no matter how hard you dieted, if it made you miserable I think most of us would want to do something about it if such a treatment was available.

So with any type of treatment that is ‘elective’ ie not medically necessary [let’s leave your mental health, self-confidence etc out of it for a minute] the benefit to the patient has to well outweigh the risks involved in the procedure.

Benefit is ‘actual’ benefit, that is an improvement to the patient’s health [including their mental health and wellbeing] and ‘perceived’ benefit by the patient, as in, how they themselves feel about it.

Now I might have a patient who has a whole load of crowns at the front of their mouth they had done years ago. These are chipped, cracked, showing dark margins etc. [Why they had them done in the first place is another matter which we won’t go into now]. So these crowns, the patient really dislikes them, their confidence has gone down the drain, they don’t smile in photographs etc. They want to do something about them. This is understandable. As long as the dentist has completely explained the treatment required, the benefits, costs, risks, time frame involved, allowed the patient time to think about it and the patient has asked and given consent for the treatment to proceed then this re-treatment is fair enough.

No one nowadays would do this treatment on a patient from scratch ie crown all their virgin front teeth. As soon as you put a drill on a tooth it is on the long slippery slope to being lost. So anything done to a patient has to be as non-destructive as possible and the benefits, actual and perceived must be greater than the risk involved. This of course means that any reputable dentist will refuse to do treatment requested by the patient for whatever reason, if they feel that the treatment is unwarranted and will be harmful to the patients’ health and wellbeing.

Many years ago there used to be a dentist who advertised in one of the British dental rags with pictures of his ‘cases’. Usually perfectly reasonable looking young women whose front teeth he had cut down to ‘pegs’ and then crowned with a set of overly bright ‘tombstones’. Why his adverts were accepted for publication I have no idea. One can only assume that there was no one dentally qualified on the editorial body.

‘Nothing is forever with teeth’. No artificial material placed on or in a tooth is going to last forever. So why replace a patients perfectly good enamel [the tooth’s protective armour as it says in the advert] with something that is artificial, will chip, break, show the margins, need replacing probably many times over a lifetime? It doesn’t make sense. Think of the cost if nothing else!

Now obviously there are often very good reasons for crowning a patients front tooth;- car crashes, olive stones, trips and falls to name but a few but anything done, should be done in the least destructive, minimally invasive way possible.

I find it very strange when patients say to me of a previous dentist ‘He/she just did ‘whatever’ to me’.

What on earth were they thinking of? Why didn’t they say ‘hang on a minute I’d like to know a bit more about it first’? You wouldn’t let someone drill a hole in your leg and fill it full of metal or plastic resin without a ‘by your leave’, so why would you let someone do it to your tooth? Your tooth is as alive as your leg, it’s part of you and connected to the rest of you by its blood and nerve supply. I’m not saying the treatment was unnecessary, it may be just a question of bad communication and a lack of information. You have to give consent to treatment and to give consent you have to be ‘enlightened’, that is, not only do you have to be ‘informed’ about the treatment proposed you have to understand it. The dental team’s job is to try to put the information necessary to you in a way that is understandable. This could be as simple as a pencil sketch or as sophisticated as a 3D computer demonstration.

Non-destructive Cosmetics.

So nowadays the only type of elective/ ‘cosmetic’ treatment done in dentistry should be as minimally invasive and non-destructive as possible.

Now let’s get this straight before we go any further there is no such thing as a ‘Cosmetic Dentist’. It is not a speciality recognised by the GDC [General Dental Council]. There are no further qualifications in ‘Cosmetic Dentistry’. All of us do ‘cosmetics’ ie we try to make our restorations look nice and we might do minimally invasive treatments to improve someone’s appearance at their request. By definition if you are going to have ‘cosmetic dentists’ that implies that the rest of the profession are ‘non cosmetic dentists’, well who would want to be one of those?

There are dentists however who specialise in ‘cosmetics’ that is they limit their practice to bits of dentistry they enjoy/ are good at and that may be the more ‘cosmetic/ appearance improvement’ side. Just like you might have a painter and decorator who specialises in special finishes like marbling. There is nothing wrong with this and there are some very talented, knowledgeable, artistic, ethical practitioners in this field.

For further information visit The British Academy of Cosmetic Dentistry at http://www.bacd.com The BACD’s mission ‘is to make a difference to peoples lives by providing exceptional, ethical, cosmetic dentistry’.

Elective [rather than replacement] non-destructive cosmetic treatments encompass; – orthodontics, bleaching and adhesive dentistry [sticking things on to things].

Orthodontics.

Orthodontics [tooth straightening/ moving etc] is a speciality [as recognised by the GDC see Chapter 22] within dentistry. It takes many years to train. All of us with the basic qualification are allowed to perform orthodontics but orthodontics has become so complicated and sophisticated to produce much better results than years ago, that I don’t think many of us in general practice would attempt anything other than the simplest treatments if that.

You can have orthodontics at any age, obviously most is done on children and young people as at that age you have time on your side, the patient is still growing and you can go for the ‘perfect’ [or as near to perfect as you can achieve] result. However since one or two people in the public eye have been seen with braces people have started to realise that there is no age bar. There are quite a lot of adults who have things about their teeth they don’t like. They have not had orthodontics when younger ether because it wasn’t offered/picked up, they didn’t fancy the idea of treatment at the time, they played a wind instrument so it wasn’t possible or because they had treatment but they didn’t follow instructions in wearing their retainers and the treatment lapsed.

Two very common issues adults have with their teeth are; – crowding of their lower front [anterior] teeth and slightly crooked upper anterior teeth.

As we all get older we get a phenomenon with our lower front teeth called ‘mesial drift’, so our lower teeth shuffle forward a bit leading to crowding. This can often be simply improved by taking one of the 4 lower front teeth [incisors] out and shuffling the other 3 incisors into a nice even line. You scrutinise your teeth from 2 inches away in the bathroom mirror but most people see you from about 3’ away, ‘a social distance’. We all know irritating people who talk ‘right in your face’ and we don’t feel comfortable with it. No one on the bus is looking at you thinking ‘she’s only got 3 lower incisors’ so you can get away with a bit of an optical illusion.

If you have slightly crooked upper anterior teeth [with or without crooked lowers] then Invisalign Orthodontics may work for you. Quite a few general dental practitioners [GDPs] offer it, as it is a system of simple orthodontics invented for use by GDPs to treat the ‘social six’- canine to canine top and bottom jaw. Each case must be assessed individually, not all concerns can be addressed, it has limitations but for the right case very nice results can be achieved. If Invisalign is not applicable in your case you need the services of a specialist orthodontist. Your practice may have someone they normally refer to but if not ask your friends etc.

When it comes to simple systems like Invisalign that anyone can do, choose wisely, avoid garish adverts,’ buy one get one free’ merchants, anyone claiming to be ‘the only’ [they aren’t], ‘the first’ [highly unlikely], ‘the best’ [even more unlikely], anyone who promises the ‘earth the moon and the stars’ [you won’t get it], anyone promising ‘a revolutionary treatment just arrived from abroad’ usually the USA land of the formulistic cheerleader smile [highly unlikely] etc. Anyone too self-important who promises too much is either a crook just after your money or an idiot.

Anyone trustworthy will err on the side of caution in explaining what is achievable, give you options one of which is to do nothing and give you plenty of time to think about it first.

Bleaching/ Whitening.

Ones teeth darken with age, what often makes people realise their teeth have become a little darker is when they realise they have become darker than the crowns they had done years ago. We can now bleach teeth. The profession tends to call this whitening to discourage people from putting household or hair bleach on their teeth.

About 30 odd years ago the only thing to be done if you had darker teeth than you would like or any other unpleasing characteristic was to veneer them but now we have a much less destructive treatment for improving the appearance of ones teeth.

There are lots of different reasons for teeth being a less than perfect colour, texture, shape etc and it is absolutely essential that the cause for whatever discolouration you may have on one or more of your teeth is correctly diagnosed by a qualified dentist. There may be more than one reason present on different teeth in your mouth.

There are various different types of bleaching applicable to different problems [such as tetracycline staining, measles lines, non-vital/ dead teeth etc]. Assuming that you are not a ‘special case’ with complicated reasons for any discoloration, the easiest, most cost effective, gentlest, most researched, long lasting method is the ‘night guard/ at home’ method.

In a nut shell this is how it works; – bleaching trays are constructed from a set of models made from a computer scanned or conventional impression. They are like very thin gum shields one wears for sports, so thin you can turn them inside out. These are fitted by the dentist, the technique taught, instructions given and the patient administers the bleaching material themselves at home for several weeks as instructed returning at regular intervals to the surgery for the dentist to check all is well, see how it’s going, check the shade progression, advise on any problems that may have arisen [very rare], check the patient has mastered the technique etc. It’s more complicated than this but this is the gist of it. This method also gives the most stable, long lasting colour. How destructive is it?- well about as destructive as drinking a can of coke a cola a day, which I would rather my patients didn’t do but it’s a lot less destructive than more traditional methods of improving ones appearance.

Faster ‘in office’ methods using stronger chemicals and special lights [often erroneously called laser whitening by the public] may be applicable if you are getting married tomorrow say, but give greater relapse. Sometimes if speed is of the essence a combination of both techniques may be used.

Every case is different, speak to the professional.

Only a qualified dentist may bleach teeth. Other dental care professionals [DCPs] are allowed to bleach teeth on prescription from a dentist after a thorough examination and diagnosis of the patient’s problem. The only DCPs allowed to bleach teeth after having received the relevant training are; – dental hygienists, dental therapists and clinical dental technicians. Beauticians and hairdressers are not allowed to bleach teeth, it is illegal and several beauticians and sadly, dental nurses have been prosecuted for doing so.

A word about whitening toothpastes, these will not whiten your teeth, but they may help to keep the stains down and as long as you use a reputable brand licenced for use in the UK then they will do you no harm even if they do you no good!

Over the counter bleaching strips from the chemist contain a much milder bleach and may give you a little lift for a party tonight but the effect will not last.

A word of warning DO NOT BUY BLEACHING PRODUCTS/ KITS ON THE INTERNET. Many of these products and systems are unregulated in the UK, USA and Europe, contain strong acids, abrasive substances and can cause lasting damage to your teeth.

When it comes to bleaching teeth as a rough rule of thumb you need your teeth to be no lighter than the whites of your eyes [sclera]. The human eye is drawn to things that are unusual. If you, for example meet a woman at a party with a blob of lipstick on her tooth or someone with something horrible hanging out of their nose you can’t keep your eyes off it. So it is with ‘cosmetics’, everything has to look harmonious- ‘the pelmet has to match the curtains’ as a patient said to me once which is a very good expression. We can all name film and TV personalities whose teeth are too, unnaturally white. You don’t want your teeth to proceed you into the room, you want people to notice you, your personality, to look at your eyes when they are talking to you, not be mesmerised by your teeth. You want your own teeth but slightly nicer, you want people to think ‘she looks well’ not ‘I’m sure she’s had something done to her teeth’.

Adhesive Dentistry.

Nowadays we can ‘glue things together’ which we couldn’t do years ago. A Maserati is stuck together likewise we can stick many more materials on without having to cut into healthy teeth to achieve mechanical retention. Dental materials are constantly evolving and improving and more and more appearance enhancing treatments can be achieved without sacrificing healthy tooth tissue.

What can be stuck on depends on what bit of tooth tissue you are trying to stick it to [enamel or dentine], the forces that are going to be acting on that particular bit [is it on a biting surface or not], how dry a field you need [if you are trying to stick your tea pot together you need clean dry surfaces or it won’t stick] and a host of other considerations.

Every case is different.

In summary.

As with cosmetic surgery, fillers, botox etc the art is in the subtlety. I certainly know people who’ve had too much filler in their lips or their cheeks and I am sure we can all name people in the public eye with ‘trout pout’, ‘pillow cheeks’ or faces that don’t move and have no expression. A really good practitioner of these types of treatments knows when to stop, knows what will enhance but not obliterate or look unnatural. Less is often more in these situations.

So it is with ‘cosmetic’ dentistry. If a patient wishes to improve/ change /enhance the appearance of their teeth anything done must be as minimally destructive as possible. Modern dentistry thanks to improving materials, techniques, philosophies and understanding of tooth biology means more and more appearance enhancing effects can be achieved with minimal destruction of healthy tooth tissue.

There is still a place for more ‘traditional dentistry’- crowns, veneers etc but only if a gentler treatment is not possible or will not achieve the desired effect.

I find for most people who are not a ‘special case’ just teeth darker than they would like, a few crooked bits here and there, they may even be enquiring about veneers, if I just bleach their teeth first they are often so pleased with the result they forget about their other concerns.

Most people are looking at you from a ‘social distance’ about 2-3’ away, they are not scrutinising the little irregularities in your teeth as you do in the bathroom mirror they don’t see those. You want your teeth to look natural, the little odd bits are part of the personality of your face.

You want to look like you and you alone, you are unique.

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