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Ethics in cosmetic dentistry

June 1, 2008
The California Gold Rush of 1848 drew tens of thousands of speculators in search of riches.
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For more on this topic, go to and search using the following key words: L.D. Pankey, Dr. John Kois, AACD, Code of Ethics, cosmetic dentistry.

The California Gold Rush of 1848 drew tens of thousands of speculators in search of riches. Fortunes were quickly made, but then the gold ran out. The ghost towns and broken lives that were left behind are a reminder of how not to handle a great opportunity.

A rush occurred in the 1980s and 1990s in dentistry, and many dentists have similarly been drawn to stake their claim in the opportunities that have resulted from the cosmetic revolution. New materials and techniques were developed. Cosmetic pioneers taught others skills to restore teeth with a natural, esthetic beauty that had never been achievable.

At the same time, baby boomers began to embrace self-improvement, bringing them to dentistry in unprecedented numbers. The pieces were put into place for the most magnificent opportunity dentistry had seen in decades, and how we handle this opportunity could easily determine the future of our profession.

Will we be seen as opportunists and speculators, like the gold miners, or will our deserved reputation as dedicated and concerned professionals be realized? The answer to this question will be decided by the ethics we establish and the way we govern within our profession.

The American Academy of Cosmetic Dentistry, the largest cosmetic dental organization in the world, has established ethical standards for its members. The Academy's Code of Ethics has been honed and refined through the years, and now sets a standard that I think is appropriate for all dentistry. The code addresses such items as patient records and confidentiality, nondiscrimination in patient selection and treatment, representation of care and fees, informed consent, and the importance of continuing education.

Beyond this, the AACD has worked hard to create an Accreditation process that is tough, yet fair, to those who choose to take on the challenge of striving for excellence. As a result, through the AACD Accreditation process, dentists and patients alike can be assured that the designation of Accredited Member or Accredited Fellow represents high clinical standards and sound ethical principles.

Esthetic dentistry should never be concerned only with smile beautification without thorough examination and addressing pathology of the entire masticatory system. Ethics remains a topic of interest among members of the AACD. As a profession, we should constantly strive to elevate the standards by which we govern our behavior.

Ethics is a branch of philosophy that deals with how we should live — the idea of good and the concepts of right and wrong. It is about how we relate to other human beings, about living the best kind of life personally and professionally.

Ethics and legal issues, of course, are not always the same. While some acts are legal, they may not be ethical. For this reason, we must seek the guidance of others in ethical matters as we do in other professional aspects. While what is ethical can vary from society to society, we do have an obligation to determine what is right within our “society” and apply those definitions to one another.

Dr. John Calamia, professor at NYU, has said there are “ethical questions that should be asked in developing one's philosophy of treatment, consistent with the best interests of our patients. We are challenged to do the right thing in providing these often elective procedures.”

Dr. John Kois, president of the American Academy of Esthetic Dentistry, has a unique perspective when viewing ethics: “The future of dentistry will ultimately be guided by our freedom to make integrity-based decisions that rely on the strength of scientific evidence, not commerce. All our clinical decisions must begin by determining an individual's risk for future disease even before he or she has expressed it. This is the core of our prevention protocols. All patient treatment is then directed toward reducing risk with therapy. Until we have more objective data with better metrics, much of our clinical decision making will continue to be emotionally driven and empirical. It will make us more vulnerable to these moral and ethical deliberations that are often confused with our inability to make a proper diagnosis. Diagnosis is the key and only the patient at risk requires treatment.”

Dr. Richard Simonsen, DDS, MS, dean of the College of Dental Medicine, Midwestern University, has outlined a series of questions to challenge dentists who undertake cosmetic care. They serve as self-evaluation for each of us. Paraphrased, they are:

  • Are the credentials you post widely recognized in the dental community?
  • Do you rely on proven science to approach your care?
  • Are you totally honest in describing your clinical skills and education?
  • Do you insist on a clear policy of fully informed consent?
  • Do you always hold yourself to “first, do no harm”?
  • Do you charge fair and honest fees?
  • Do you rely on the expertise of specialists when it is needed?

Dr. Simonsen's questions point us in the right direction in developing a personal blueprint for ethical choices. There are other voices that add dimension to our process. Drs. J.D. Bader and D.A. Shugars suggest that the implicit assumption accompanying any treatment is that the benefits of that treatment will outweigh any negative consequences. In short, this treatment is better than no treatment at all. This simple guideline hovers over us every time we approach a patient and consider his or her care.

Cosmetics pose a unique challenge because they are so highly discretionary. For that reason, we must be a patient's advocate and remain more concerned about his or her issues than our own. We must challenge ourselves to remember we are serving our patient, not vice versa.

In 1952, Dr. L.D. Pankey said, “It's the moral obligation of the dentist to bring his ability up as close to his capability as possible in accord with his talent. Learning the technique is not enough. A dentist needs to learn how to take care of the whole person.”

I propose a series of questions that will help you define an ethical code of conduct. I invite you to consider each thoughtfully and commit your answers to paper for continual review and revision.

  • What is the dentist's role in persuading or encouraging a patient to have cosmetic care?
  • What role does the dental team take in understanding the patient's personal finances, and what difference should that make?
  • How much tooth reduction is appropriate for a cosmetic solution?
  • What constitutes fully informed consent? How much information is enough? How much is too little?
  • Who should prioritize highly discretionary care over care that is needed to address pathology and breakdown?
  • What obligation do we have in addressing occlusion and TMJ issues in conjunction with cosmetic care?
  • What is the scientific literature on which we base our esthetic approaches? How much time must we spend staying current on research? At what point is a procedure sound enough to put into regular use?
  • How do we learn from our failures? What do we do with our failures? What precautions must we take to avoid failures?
  • When is it appropriate to refer for specialty care over proceeding with cosmetic restorations? For example, is orthodontics or orthognathic surgery a better option in some cases?
  • How do you promote yourself and your services, and is this promotion scrupulously honest?

I pose these questions and share the thoughts of others to begin a broader dialogue about ethics, especially as they apply to cosmetic dentistry. I look forward to the discussion. I believe the better prepared we are to handle this golden opportunity, the more successful we will be.

References available upon request.

Dr. Mickey Bernstein has practiced dentistry for 33 years in Germantown, Tenn. He is an Accredited member and currently President of the American Academy of Cosmetic Dentistry. A Fellow of the Academy of General Dentistry, he is an alumnus of the L.D. Pankey Institute. Contact Dr. Bernstein via phone at (901) 754-0540 or e-mail at [email protected].

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