Ethical marketing in ‘aesthetic’ (‘esthetic’) or ‘cosmetic dentistry’ part 3

The dangers of emotive words or making claims of having extra skill or talent in ‘cosmetic’ dentistry

In the last ten years or so there has been an increase in the influence of business coaches and marketing ‘experts’ on the dental profession. Many of these ‘coaching gurus’ have relatively little experience of dentistry themselves but have a lot of experience of commercial selling and promotion. They are usually proficient in slick presentations on how to get patients to accept expensive ‘cosmetic’ dental treatment and they emphasize the business/financial side of dental practice rather than the ethical care of patients.

Some easily influenced, unwitting or commercially aware dentists may be seduced into using words or pictures that provide unrealistic images to patients. For instance, the word ‘perfect’ is an absolute term, a bit like sterility or virginity. Things cannot be a ‘little bit sterile’ or a ‘little bit perfect’. One cannot be ‘a little bit of a virgin’. You are, or you are not. Things are either perfect, or they are not. ‘Perfect’ or ‘perfection’ would not be used in relationship to aesthetic dentistry by any sane, sensible dentist. ‘Perfect’ is not the same as ‘nice’, or ‘acceptable’, or ‘better’. ‘Perfect’ means that nothing, even in one's wildest dreams, could be better. Sadly, in relationship to cosmetic dentistry, patients are the sole judge of that and, if they start with unrealistic expectations due to the practice promoting unrealistic images and, if there is any shortfall in ‘perfection’ as judged by the patient or his/her family or friends, then to them the ‘cosmetic’ product or service is lacking in ‘perfection’.

This cautious use of terms should extend to avoiding references to a veneer or a crown as being a ‘permanent’ veneer, or a ‘permanent’ crown, or a ‘permanent’ implant-retained crown or a ‘permanent’ bridge (Figures 2 and 3).

If it transpires that there is any problem with any of those restorations, at any point in the future, then clearly the veneer, crown or bridge or implant is lacking in ‘permanency’. Lawyers and many patients understand the word ‘permanent’ as being an absolute term and not a relative term. Dentists often use the word ‘permanent’ to distinguish it from ‘temporary’ or ‘provisional’, eg in referring to a filling or a crown or bridge. Sadly, there is no such thing as a ‘permanent veneer’ or a ‘permanent crown’. Pretty much every restoration or restored tooth fails in the long term, either partially or completely, and it is just a matter of what is left when that failure occurs, unless the patient decides to exercise his/her option to die before the dental failure can occur. ‘Death’, on the other hand, is an absolute term.

A restoration can certainly stay in position, such as a nicely made and well matched veneer or crown, but if there is significant recession around the veneer or crown and the patient later on finds that unacceptable because of his/her lip line showing this, then the responsibility and financial costs of the replacement of the restoration (particularly if it is placed for elective aesthetic reasons) lies fairly and squarely with the dentist if they have made a claim that this was a ‘permanent restoration’. It is unwise to use the word ‘permanent’ in relationship to dentistry of any sort and the word ‘perfect’ and ‘perfection’ should be deleted from any sensible dentist's vocabulary. Much better words or phrases to use when referring to possible future dental cosmetic changes are ‘acceptable’ or ‘reasonable’ or ‘a bit better’ or ‘may result in appearance improvements in the medium term’ (Figures 4–9).

Advertising one's practice with a crassly stupid name such as the ‘ABC or XYZ Perfect Smile Practice’ or something similar is simply asking for trouble. Marketing type buzzy or glitzy words used in a practice name could well attract a substantial number of patients with unrealistic expectations to the practice. Such patients could well have a fastidious approach to even minor dental imperfections, a tendency to have obsessive compulsive characteristics and, in some cases, could be patients with body dysmorphic disorder. Sometimes these sorts of patients will bring in to the dentist magazine images of film stars, actresses, models, or minor airhead celebrities whose teeth they particularly admire. Many will hope that if those types of teeth, or shape of teeth, or colour of teeth are provided for them, then their other physical deficiencies will be minimized. In other words, they can look generally ‘ugly’ but they may well have a distorted mental image of themselves. As a result of this, they might believe that, if they could just have their teeth changed then, somehow, as a consequence of this dental change, the rest of their bodily imperfections would be minimized.

These expectations are sometimes hugely unrealistic and can be part of a psychiatric problem of ‘displacement’. In other words, they feel that if only they could get one aspect of their body ‘perfect,’ such as their teeth, so that these were made to look extremely white and extremely even, then doing that will somehow produce such a startling improvement that their other problems of being overweight, with a poor complexion, a crooked nose, cross eyes, poor hair, big ears and questionable physical shape, will all be magically abolished by having ultra white, even, gapless teeth. Sadly, they have as much chance of that happening by changing just their teeth in that way as they have of winning the national lottery. Any sensible dentist needs to help them, particularly well in advance of any destructive treatment, to be much more realistic about what aesthetic dentistry might possibly achieve for them in their individual and particular circumstances and also stress the lack of ‘permanence’ of most of dentistry (Figures 4–9).

Unrealistic claims and negligence in cosmetic dentistry

If ‘aesthetic’ (‘esthetic’) or ‘cosmetic dentists’ hold themselves out to have a particular level of skill and expertise then they have a duty of care to discharge that level of duty of care, skill and expertise. This may well be the standard against which they will be measured if, and when, a question of negligence arises. In determining negligence there has to have been a breach of professional duty in terms of the standards actually achieved in a particular case.

A breach of duty is one of the essential requirements in any finding of negligence. In such cases, reference may frequently be made to acceptable professional standards which reflect a ‘reasonable, responsible and respectable body of dental professional opinion’ in operation at that time. In such a case an ‘expert opinion’ is usually sought. In litigation involving defending a claim of negligence, the treatment undertaken needs to be able to be presented as being treatment that a representative body of respectable, reasonable and responsible dentists, working in that field, at that time, would have undertaken in similar circumstances. Unfortunately, it would usually be ‘specialists’ who would be asked to provide such evidence in their report to the court.

GDC recognized specialists would usually be judging the treatment in relationship to the benchmark of other specialists working in the same field at that time. General practitioners could be judged against other general practitioners but only if they claimed to be generalists. There is no GDC recognized specialist list in ‘Cosmetic Dentistry’ and advertising oneself as though one exists is fraught with dangers.

Membership of one of various new academies should not be used for dishonest self promotion or to deceive the public at large, either accidentally or deliberately, that this is equal or superior to a legitimate postgraduate university degree or prolonged and accredited Royal College of Surgeons training.

The required duty of care and the way in which it might be measured might be affected by the basis on which the dentist entered into the contract in undertaking to provide ‘cosmetic dental treatment’ for the patient in question at that time. If there was an agreement (or implied agreement, eg based on the self promotional name of the practice) between the patient and the dentist that the dentist would provide ‘The Perfect Smile’ and a lot of destructive dentistry was then undertaken in order to provide that ‘Perfect Smile’ and the patient subsequently judges the outcome not to be ‘perfect’, there can easily be a claim for breach of duty, negligence and, as a consequence of that claim, for all the associated remedial treatment, damages and legal fees.

This possible claim isn't limited just to the cost of provision of any new treatment, usually to be undertaken by a different dentist and often with higher fees than the original fees incurred. Potentially, it also involves compensation for the pain, suffering, psychological distress, loss of amenity, loss of the patient's time and/or income lost, while he/she is having re-treatment.

Liability in such cases can well extend to all the remakes of the dentistry for the lifetime of the patient and it can also involve general and specific damages. This is because, if he/she had not had the negligent cosmetic dentistry done, the remakes would not have been needed. Many such patients, when they realize that they have been cheated out of their invaluable sound enamel and dentine, as well as their money, by someone they trusted to do the right thing for them can become formidable litigation foes.

This dispute can lead to disciplinary action with the regulatory body such as the UK General Dental Council, if the patient or his/her ever helpful lawyer, complains to them.

There is the added risk that the litigious patient's lawyers, or a specialist litigation firm, runs the case for the patient on a ‘no win no fee’ (conditional fee) arrangement. Such firms have, in the past, having obtained an agreed financial settlement both for themselves and the patient, as an added bonus, thrown in a complaint to the General Dental Council (GDC) against the dentist as a ‘sting in the tail’ feature of their services, ie providing continued vindictiveness against the defendant dentist involved in the case.

In many cases, the contract for the provision of aesthetic or cosmetic dentistry is verbal rather than written, although both dentist and patient may rely on other material to demonstrate their understanding of the nature and extent of the contract. In ‘aesthetic’ or ‘cosmetic dentistry’ this may include reference to a dentist's website, practice brochures, information leaflets or internal practice promotion documentation, which may be used to illustrate the discrepancy between what was actually achieved and what had been ‘promised’ based on such promotional or other information material (Figure 10).

Records should clearly document that the limitations or negative aspects of the supposedly ‘cosmetic’ treatment (particularly if it involves serious sound tooth destruction which is often anything but cosmetic) had been discussed in detail and preferably these warnings should be confirmed in writing. The likely, preferably modest, claim for longevity of any restoration to be provided should form a sensible part of any dentist's documentation who regularly, or infrequently, undertakes ‘cosmetic dentistry’.

Large entries in, for example, Yellow Pages or flash websites with the dentist's best cases on them, beautifully illustrated for all to see, can attract patients with unrealistic expectations. There is a real and present danger that, intentionally or unintentionally, dentists can enter into a verbal contract to provide a standard of care which is very much higher than a ‘reasonable standard’. For instance, a large or flash sign on the practice saying ‘The XYZ Perfect Smile Practice’ could be considered by some patients as providing an implied contract to achieve ‘perfection’ for them, regardless of the level of the problem of their dental appearance. By undertaking ‘cosmetic’ treatment for such patients, in such a named environment, it is possible to open the door to the possibility of being sued for breach of contract (Figures 10 and 11). This could be instead of, or in addition to, being sued for the negligent provision of treatment.

Guarantees and warranties in supposedly ‘cosmetic’ dentistry

Entering any contract offering guarantees and/or warranties poses particular problems, especially if the treatment proposed includes any terms such as a ‘permanent crown’ ‘permanent implant’ or ‘permanent veneers’ or ‘a perfect smile’.

Some dentists, for their own commercial gain or marketing reasons, may make a statement that they will replace or remake any veneer, crown, implant-retained restoration, or implant free of charge if it fails within a defined period of time. Restrictions may, or may not, be placed on that guarantee, such as limiting the offer to only fair ‘wear and tear’, or imposing other conditions of one kind or another. However, if the restoration fails within a specified time, even by a day, and the circumstances of failure were not specifically excluded by the terms of the guarantee or warranty, a dentist generally would be liable, contractually, to replace the work free of charge, whether or not it was negligently provided or, indeed, irrespective of its quality at the time of provision or delivery. This is a matter of contract law, not one of negligence or tort. Many such cases could be successfully defended were it not for the presence of the ‘guarantee’ given by the dentist about the treatment provided. Some dentists probably offer these supposed ‘guarantees’ in their desire to obtain larger fees for their version of ‘cosmetic’ dentistry (Figure 11). It is wise to err on the side of caution in any claims for the beauty of the outcome and not to make promises that your hands can't keep.

Maintaining the appropriate records in aesthetic dentistry

If problems arise in a ‘cosmetic’, or ‘aesthetic’ case, excellent records are necessary to help the dentist, or anyone else looking at the case subsequently, to understand not only what was done, but also why it was done, when it was done, how it was done and by whom.

Records should contain clear records of conversations including any implicit or explicit promises that were made at any point. It is important to use moderate language in relationship to any promises that are given to a patient which could later be seized on by the patient, or their legal representative, if there is a dispute about the eventual appearance outcome.

Pre-operative photographs are an invaluable record. Study models can give a good long-term record of the position of the teeth before treatment. Clearly, they can't illustrate colour, which is why digital images need to be taken from a variety of angles, preferably with the teeth in the intercuspal position, but also from a variety of angles, including those with the lips widely retracted and the teeth not in contact with one another. This frequently helps to profile the irregular dark spaces around teeth, which are often the source of the patient's unhappiness about his/her dental appearance. In other words, often it is not the shape of the teeth themselves that is the problem but rather the irregular dark spaces around the teeth which patients actually complain about. This is often the case even if they cannot always describe the real source of their specific aesthetic unhappiness (Figure 12 and 13).

Baseline information should obviously record patient identification data, as well as a comprehensive medical history and dental history. The records of the clinical examination should reflect appropriate detail and the justification for, and the diagnostic yield of, any radiographic examination, especially if there were any discoloured front teeth involved in the possible treatment options (Figure 14)

It is important that a diagnosis of the ‘cosmetic’ problem or problems is entered in the records. This is often missing from ‘aesthetic’ or ‘cosmetic’ treatment notes or plans. There needs to be clear reference in the notes to a sensible consent process. This should include details of what aesthetic changes were proposed or discussed or shown to the patient, eg with a walking diagnostic composite temporary bond up (see Part 2 in this series Dent Update 2012; 39: 406, Figures 21–24 for details).

This needs to be recorded clearly, as well as the relevant advantages and disadvantages of the various lines of possible treatment offered. The patient's preference for a particular type of treatment that was chosen also needs to be recorded, together with the agreed reasons for doing such treatment, especially if the dentist has, or had, any reservations about carrying out this particular treatment. Progress notes should also be detailed as to what was undertaken at each visit. It is also helpful if each of these ‘cosmetic’ stages are photographed. If there is any dispute which causes the patient to consider leaving the practice, particularly in the middle of treatment, this should be recorded in great detail because, at that stage, it is reasonable to assume that the patient is now ‘in the market’ for something very different from what has been achieved so far in changing his/her facial or dental appearance.

Every effort should be made to maintain contact with such patients, particularly if they are unhappy about some aspect of their appearance. It may be prudent under these circumstances that an experienced and reliable receptionist or nurse has the conversations with the patient and documents these conversations, because the treating dentist can often become frustrated by the apparent ‘limitless demands’ from the ‘nightmare patient’.

In any such disputes it is prudent to remember that patients have access to their health records under the Access to Health Records Act 1990 and under the Data Protection Act 1998, as well as the Freedom of Information Act 2000. It is wise, therefore, to keep the notes sympathetic in their tone, regardless of any perceived ‘aggravation’ or ‘irrationality’ in the patient's apparent position. A note such as ‘Mad Cow Disease’ or ‘Barking’ does not look quite so funny in court.

Obtaining consent in aesthetic dentistry

If a treatment is elective in nature, as most of aesthetic or cosmetic dentistry is, then obtaining proper consent for it is a vital component of the process. The patient has to be competent to give consent. They have to be able to give it voluntarily and consent has to be based on adequate information and knowledge of what is really being proposed.

Consent is not a single event but rather a process and is defined by the UK Department of Health as follows: ‘The voluntary continuing permission of the patient to receive a particular treatment. It must be based on the patient's adequate knowledge of the purpose, nature, likely effects and risks of that treatment including the likelihood of its success and a discussion of any alternative to it, including no treatment.1

In a ‘cosmetic’ or ‘aesthetic’ case, when deciding on what is in the patient's best interest, the ‘Bolam Test’2 will usually apply. In the ‘Bolam Test’ a dentist must act in accordance with a responsible and competent body of relevant professional opinion at that time when making decisions about any such treatment. A dentist who is in any doubt about any aspect of the ‘cosmetic’ treatment should probably consult another, perhaps more experienced, dentist, and record any discussions that took place with that colleague about that particular patient's problems in that patient's records.

A large part of the consent process (‘consense’) is informing the patient properly and in detail of any reasonable options available to him/her. These might include a referral to a specialist. It is sensible to record in the notes the details of any important conversations that actually took place. These should confirm what option the patient chose at that particular time (Figures 12–14). This is particularly important because subsequently the patient may claim that he/she was not informed adequately, or at all, of the range of options. They, or their lawyers, may state later on that they never had, or never declined, the offer of an earlier referral to a specialist.

Consent is really about treating patients with courtesy and recognizing their dignity and rights as individuals to make their individual choices. Consent should be part of an ongoing dialogue between the patient and the treating dentist. For consent to be informed the following information needs to be made available to the patient:

Ethical duty to disclose information when things go wrong with aesthetic dentistry

It is important that the patient is fully informed of any problems, no matter how embarrassing such a disclosure is likely to be to the treating dentist. The patient has a legal right to know that a particular problem has occurred, even if it was unforeseen, or even if it may potentially undermine the patient's confidence in the dentist.

Duty of care

The standard of care in the general law of negligence is ascribed to the apocryphal ‘Man on the Clapham Omnibus’ but the duty of care expected from a dentist is greater than this. The ‘Bolam Test’ sets out the standard of care required by dentists in clinical negligence cases.2 This is ‘the test of the standard of the ordinary skilled man or woman exercising and professing to have that special skill. A man or woman need not possess the highest expert skill. It is sufficient if he/she exercises the ordinary skill of the ordinary competent man or woman exercising that particular art. A doctor is not guilty of negligence if he/she has acted in accordance with the practice accepted as proper by a responsible body of medical men or women, skilled in that particular art’.

In other words, a doctor (dentist) is not negligent if he/she is acting in accordance with such a practice, merely because there is a body of opinion which takes a contrary view.

Clinical judgement and differences of opinion in aesthetic dentistry

If you were to ask 10 different dentists about an aesthetic problem you would probably get 11 different treatment plans and options. In view of those acknowledged differences of opinion, it is scarcely surprising that there would be at that time, and there will be in the future, a body of opinion which would take a contrary view of the treatment actually undertaken.

There is usually more than one reasonable way to provide treatment in any given aesthetic/cosmetic situation. The law recognizes that a genuine difference in clinical opinion or treatment does not mean that it was necessarily negligent. In the Hunter v Mann case, Lord Clyde stated ‘In the realm of diagnosis and treatment there is ample scope for genuine differences of opinion and one man (for which read ‘woman’) clearly is not negligent merely because his conclusion is different than those of other professional men. A true test for establishing negligence in the diagnosis or treatment on the part of the doctor (dentist) is whether he has been proven to be guilty of such a failure, as no doctor of ordinary skill would be guilty of, if acting with ordinary care’.

In other words, a dentist would not be found negligent if he/she was able to demonstrate that there were two or more schools of thought existing in a given situation, one of which was allowed at that time.

It might be comforting to a dentist to think that he/she could rely in any possible dispute on some of his/her peers to determine what an ‘adequate standard of care’ really is and that this aspect of a claim is not going to be left to a judge. However, in 1999 in the UK, the Civil Procedure Rules (CPR 1999) changed matters in relationship to the ‘Bolam Test’.

The Civil Procedure Rules(CPR) state clearly that the duty of the expert in clinical negligence cases is to the Court and not to the person who pays him/her. Such ‘experts’ therefore cannot be used as a ‘hired gun’ to support dubious, supposedly ‘cosmetic’ dental practices or procedures.

A significant change in UK law relates to what is called the ‘Bolitho Test’. This resulted in a modification of the ‘Bolam Test’ in that having a responsible body of opinion to support the actions of a doctor (or dentist) is now not enough. That professional opinion must now be able to stand logical analysis. If a judge finds that the opinion of one expert doesn't stand up to logical scrutiny, then the ‘Bolitho Test’ allows the judge to choose the opinion of the other expert. The use of these adjectives – responsible, reasonable and respectable – all show that the Court has to be satisfied that the exponents of the body of medical (for ‘medical’ read ‘dental’) opinion relied upon can demonstrate that such an opinion has a logical basis. In particular, when cases involve, as they often do in ‘cosmetic’ dental cases, the weighing of risks against benefits, the judge, before accepting a body of opinion as being responsible, reasonable or respectable, will need to be satisfied that, when forming his/her view, that the experts have directed their minds to the question of comparative risks and benefits and have reached a defensible conclusion on the matter.

A new definition of a ‘responsible body of medical opinion’ must be that the opinion is now ‘logically defensible’. Many extreme treatments in cosmetic dentistry undertaken for relatively minor problems would struggle to be ‘logically defensible’ especially where ‘ear to ear multilectomies’ have been involved.

Contributory defences to claims in negligence

It is clear that the dentist has a duty of care towards any patient that he/she treats, but patients also have certain duties and responsibilities to provide correct information, follow reasonable instructions and generally act in their own best interests. In such situations, the standard that needs to be met is that of a ‘reasonable patient’. This is important when seeking to establish whether the actions, or inactions, of patients have contributed to their problems. If it can be proved that, on the balance of probability, the patients' actions contributed to their problems, then there could be a defence to a claim of negligence.

For instance, if a patient were to open a bottle of beer with his/her new porcelain veneered teeth and, in doing so, broke one or more of them, this adverse outcome would probably be deemed to be due to the patient's actions. However, this very much depends on the facts of the case and whether sufficient written information was provided for the individual patient to allow him/her to make a reasonable decision (eg were they specifically warned not to open beer bottles with their teeth?).

Records reflecting an understanding of the information given to patients about possible ‘cosmetic’ treatment

Giving information to patients is one thing, but whether or not they understand any, or all, of such information is an entirely different matter. The law places a strict duty on the clinician to explain to the patient, in words or language that the patient can readily understand, the essential nature and purpose of the ‘cosmetic’ treatment that he/she is to undergo.

To avoid the question of negligence and consequent liability, the dentist must have taken ‘sufficient care to convey to the patient the gravity, nature and extent of risks specifically attendant on the procedure’. The dentist also needs to be reasonably certain that the patient understood this before undertaking any irreversible or destructive ‘cosmetic’ treatment.

Particular care is advised, in view of possible problems of communication between people from different countries, especially if either the dentist or the patient has any difficulty due to language skills or, possibly, their accents. A skilled interpreter may be required from time to time, for either the dentist or patient, to help convey the subtleties of language about any proposed elective ‘cosmetic’ dentistry. Under such circumstances, written confirmation of these discussions is a sensible option to avoid misunderstanding becoming a major problem.

Advertising and ‘cosmetic’ or ‘aesthetic’ dentistry

‘Aesthetic’ or ‘cosmetic’ dental treatment is often undertaken with the best of intentions in an effort to provide a benefit to the patient (‘beneficience’), preferably without doing any real damage to the teeth (‘non-maleficience’). However, such interventions do not always go as the patient or dentist hoped that they would at the outset. Ultimately, the patient is the sole arbiter of whether an ‘aesthetic’ or ‘cosmetic’ treatment is in line with his/her expectations. In fact, the result may not be the greatest possible clinical outcome but, if it is generally in line with the patients' expectations, or even a little better than their expectations, it is unlikely that there will be much complaint.

The real difficulties occur when there is a serious mismatch between the ‘cosmetic’ outcome that is actually achieved and what the patient was hoping, or expecting, the supposedly ‘cosmetic’ treatment was going to achieve. This is particularly a danger if the expectation of an improvement was largely based on any advertisement of any type by the dentist (such as ‘ABC Beautiful Teeth Practice’ or ‘XYZ Perfect Smile Practice’ or the ‘XXXX Best Dentist Spa’ or ‘Emporium’). It is often at this stage, unless the history has been very well documented, that disputes arise and are difficult to defend.

The patient may very well claim that he/she was led into having ‘cosmetic’ treatment by the dentist's advertisements, but that the dentist, before doing this treatment, did not point out in any real detail, or with any great force, that there was a significant chance of failure of the elective treatment, either early on with the treatment, or later on in his/her life. For instance, a multiple porcelain veneer case can look very good initially and form part of a dentist's advertisement or website but, as often happens when these are placed on top of previous composite restorations, or when there is more than a third of the tooth missing, failure of porcelain veneers is not infrequent.4 Once a veneer or more than one veneer produces problems or comes off, it involves acute embarrassment to the patient, and often the dentist, particularly if the patient seeks care elsewhere. If there are frequent failures of de-cementation, or pain, or the matter is not dealt with appropriately, sympathetically, or in a timely manner, then the potential for complaint or litigation is considerable (Figure 17).

It is not ethical, not fair nor reasonable to withhold relevant information which could be later construed as cheating the patient out of his/her sound enamel and dentine, as well as money, largely for the benefit of the treating dentist.5

Under such circumstances, patients often maintain that they'would never have agreed to have’ the orthodontic, surgical, prosthodontic or other ‘cosmetic’ procedure undertaken if they had been made aware earlier on, or during the discussions, or the treatment planning stage, of the fact that there was any potential for long-term problems (Figures 17 and 18). In such circumstances, they can allege that these balancing negative aspects of the treatment were deliberately withheld from them and that it was this lack of knowledge of possible further complications that finally influenced their decision to go ahead.

Many patients, like dentists, have 20/20 vision with a ‘retro-specto-scope’. In other words, with the benefit of ‘hindsight’ it is easy to be wise. In such disputes about ‘cosmetic’ surgery or dentistry various allegations can, and are, made by unhappy patients such as:

Patients often allege that they felt that they were under no obligation themselves to seek out any or all of this balancing information. Instead, some litigious patients can contend that it was the ethical, or moral, responsibility of the dentist who was providing the elective ‘cosmetic’ treatment to draw their attention early on to any potential, or possible, problems. This, they claim, is because the ‘professional dentist’ should have been in possession of those balancing facts. It is not infrequent for patients to suggest that the dentist advertised his/her skills, or products, in a particular way in order to induce them into having treatment but, in so doing, conveniently neglected to inform them of those potential longer term problems in order to ‘make the sale’ of the ‘cosmetic’ treatment largely for the dentist's own financial reasons.

In such disputes, it is sometimes alleged that the dentist advertised him/herself, directly or indirectly, or claimed to be a ‘specialist’ or ‘expert’ in the ‘aesthetic’ or ‘cosmetic’ field when, in truth, this was not the case. In fact, he/she may well not actually have been as highly talented, qualified, brilliantly artistic, or experienced, as the patient was led to believe via advertisements, websites, practice name or with any other information supplied to the patient generally or specifically in any discussions.

Patients can also then contend that there were other, more talented, more experienced or more highly qualified clinicians to whom the dentist ought to have referred them, given the full extent or complexity of their initial presenting clinical problems (eg the dentist should have sent them to a ‘bondodontist’ or an appropriately trained orthodontist or orthognathic team rather than the dentist doing ‘immediate orthodontics’ with a diamond bur, eg for extensive porcelain veneers or other experimental CAD CAM ceramics.5,6

It is also sometimes suggested that the dentist should have known, if he/she had been as experienced as claimed, that the prognosis for the treatment undertaken was actually quite limited (Figure 17 and see Part 2 in this series Dent Update 2012; 39: 391, Figures 1–4, 10). They may allege that the dentist did not bother passing on that information, or that the dentist neglected to discuss, in advance, the future prognosis or potential problems, or the possible later costs to the patient of that treatment.6

Not infrequently, such patients state that, had they known that the prognosis was so guarded, they would have chosen a different option, including not having that particular treatment, or any treatment at that particular time, or not involving that large amount of money (Figures 17 and 18).

Most or all of these possible points need to be considered by the dentist early on at the enquiry, or discussion, stage. What is key to avoiding such problems is being able to determine accurately a specific patient's desires, ie for what exactly is he/she in the market to get, because this is a minefield for the unwary. Many enthusiastic, or over enthusiastic, or egotistical dentists may well have a great deal of self confidence in their aesthetic talents, clinical skills and dental ceramic technician back-up but some, perhaps, lack the necessary balancing self criticism. Such ‘Decent Doubt’ is sometimes referred to as an ‘Internal Critic’. This requires a dentist to be honest, reflective and self critical before and after treating patients for elective ‘cosmetic’ dentistry. Sadly, nauseatingly self congratulatory advertisements are now commonplace on websites, in commercially driven trade publications, with some ghosted testimonials and pseudo-scientific articles proliferating well beyond the point of what sensible dentists would call frank cheating of patients out of their enamel, dentine and money.

That tacky over commercialization does little good for the dental profession at large and needs to be curtailed voluntarily by the profession before regulators act as they have done in a draconian way in Australia.

Good photographs of ‘aesthetic’ or ‘cosmetic’ cases, if reviewed regularly as part of personal or group audit or clinical governance, will frequently show areas for potential improvement and help participants to learn from their mistakes or sub-optimal treatment results. Such photographs should also help to stop some dentists from selectively deleting from their memory those problems, treatments, complications and details of patients that they would much rather forget and thereby continue to advertise or draw attention to their more successful outcomes in a possibly misleading way.

On a more positive note, regular review of the problems in delivering cosmetic dentistry frequently teaches one a great deal more than the successful cases. Experience is a great teacher and, considering what it costs, it jolly well should be! The old adage that ‘experience is something you get shortly after you really needed it’ remains true, especially in the field of cosmetic dentistry.

Mistakes, sadly, are the usual bridge between inexperience and dental wisdom.