First, we do no harm

By Joe Blaes

In 1975, I finally decided that there must be a better way to fill a tooth than placing an amalgam. I was involved in a study club with several members who specialized in placing gold inlays. I had been observing several patients in my practice that had their teeth restored with gold. The margins of those gold restorations were smooth. They did not accumulate plaque and the tissue around them was healthy. I had several gold inlays in my own mouth (placed while I was in dental school) that looked the same way.

Growing up in the 1940s and 1950s, I had a fair amount of decay and a number of large amalgams that were constantly in need of patching. I decided that I would have my mouth restored with gold by one of my study club mentors. Over the next year, I had all of my posterior teeth restored with gold inlays and crowns. I paid the regular fee for this dentistry and was very happy to have my mouth fully restored. At this point, I decided that I should be offering all my patients this same option of having their mouths restored with a material that could last a lifetime if it was properly maintained.

I had been exposed to Dr. Bob Barkley (his office was close to St. Louis) in the late 1960s and had modified my exam techniques to include co-discovery and a comprehensive exam. This became the cornerstone of my practice. I took courses from Dr. Omer Reed to become more proficient in my gold inlay and onlay techniques. He had one of the first of what we call "institutes" today.

Then, in the late 1970s, we suddenly had an adhesive that allowed us to stick things to teeth. Amazing! I attended courses by Dr. Bob Ibsen and Dr. Bob Nixson on how to use these amazing new materials. Now my patients had even more options, and so did I. Both of my central incisors had the mesial corners chipped off — remnants of a childhood bicycle accident. Full crowns were my only option, but now I could finally have them restored simply and conservatively by placing some porcelain veneers. What a difference that made in my smile. My practice quickly became even more aesthetically orientated.

But the comprehensive examination and treatment plan was still the cornerstone of my practice. Treatment of the tissues remained the foundation of all treatment plans. Once the tissue was healthy and the patient could maintain that health, restoration of the teeth followed. My practice has always had a mix of "blue collar" and "white collar" patients. I was not in the affluent part of St. Louis, but I educated my patients about the advantages of restoring their mouths to optimum oral health. I would present complete treatment plans, but would show my patients how that treatment could be phased over two, three, or four years.

In the 1980s, I began to teach my colleagues the aesthetic techniques that I had learned and practiced with success. The cornerstone of these courses was always the comprehensive exam.

The point of all of this is that I am concerned by today's rush to treat everyone cosmetically. Over the past few years, we have had a multitude of "institutes" open up all over the country to teach new cosmetic techniques. How to place veneers on anterior teeth. How to cosmetically restore the posterior teeth. How to restore all 28 teeth at the same time. How to restore teeth with pressed ceramics. How to restore teeth with feldspathic porcelain.

In the rush to do cosmetic makeovers, have we forgotten the principles of ethics and morals that have made us a respected profession? Perhaps we should all take a long, hard look at how we run our practices. Is the cornerstone of our practices still the comprehensive examination, or do we fail to look past the front teeth? Do we look in the mouth and see dollar signs? Do we involve our patients in co-diagnosis? Do we present comprehensive treatment plans to our patients that explain all the options that are available to them? Do we treat the tissues first, getting the foundation in good shape to receive our great restorations?

Some of my colleagues are accusing the profession of over treatment. I would hope that we are not guilty of this because that would indicate that greed has taken over and that would be violating the social contract we as a profession have with the public. Our code of ethics is founded on the principle that "first, we do no harm." Now is a time for introspection. Each of us must examine the principles that are the bedrock of our practices. Now is the time to reaffirm our principles and once again become a trusted and highly respected profession.