Patient Communication & Treatment Planning

Mr. Davies’ desire to feel “younger and more vigorous” is part of our culture to improve our health, our bodies and our overall appearance. Esthetic dentistry is a common feature in dental journals and dentists are inundated with advertisements in popular dental magazines for new materials pushed by dental materials companies vying for their share of this market. Yet, is the dentist simply the agent for patients like Mr. Davies in their quest for an enhanced self-image? Is the dentist responsible to inform patients of their esthetic “flaws,” just as they inform them of their periodontal condition? How does the dentist balance the patient’s demand for esthetic care against questions of function and his or her own professional judgment about esthetics?

Dentists who wrote about this case chose to have Mr. Davies select the shade but to also have him approve his selection at the wax trial-denture appointment. None of the respondents chose to show him only those shades that the dentist thought were appropriate for him (whitest shade not included) or to discontinue treating Mr. Davies since he did not trust the dentist’s judgment.

At first glance, this case seems somewhat mundane, unchallenging, and perhaps easily “solved” by most dentists. However, understanding the ethics of our profession asks us to consider “the morality of ordinary practice”¹ in order to make sense of competing obligations and responsibilities. The ability to restore function and esthetics is one of the distinctive qualities of dental practice. The interplay of these qualities may be clarified by viewing two standards for esthetics and by relating these standards to oral function and patient autonomy.

Esthetics – Two Standards

Esthetics has been described as having both an objective and subjective sense – the former concerned with the beauty of the object itself (e.g., proportion and harmony), and the latter with what is beautiful in the eyes of the beholder (e.g., the patient’ s perspective).²

The objective element of esthetics and complete denture prosthodontics has been described as “an area of prosthodontics where art dominates science, where esthetics is the major concern and where knowledge must be applied to create a pleasing appearance while simultaneously maintaining oral function.”³ Creating objective esthetics requires that the dentist assess Mr. Davies oral anatomy, facial features, current dentures and photographs of the patient if possible. The dentist then makes an objective decision about tooth color, size, and morphology⁴; the arrangement of the teeth to create optimal lip support, tooth display, anatomic harmony, and phonetics; and the gingival color and tooth material.⁵ For example, one author suggests that selecting shades for complete dentures “is usually simple and problems uncommon.”⁶ while another states the “vast number of combinations in face form and size, arch form and size and the colors of hair, eyes, and complexion makes tooth selection anything but a menial task.”⁷

Prosthodontists have acknowledged the subjective esthetic preferences of patients and have, for example, identified three types of pleasing appearances: (1) the “natural look” selected by the dentist; (2) the “ideal look” characterized by a youthful appearance; and (3) the “preferred appearance” achieved by the orthodontist or represented by “small white teeth.”⁶ Mr. Davies is requesting the “ideal look” but dentists who responded to Mr. Davies’ case wondered if his concern was tooth color or perhaps other objective esthetic flaws such as the “shape or alignment of the teeth” in his current dentures, or if he had “flattened out at the incisal edges” resulting in an “older look.”

The interplay of subjective and objective esthetics illustrates one of the subtleties of dental practice. Mr. Davies, who desires to look “younger and more vigorous,” is making a subjective judgment about esthetics when he asserts, “just give me the whitest shade you have.” The dentist, however, views this sixty-year-old man with the “ruddy complexion” and wonders if a dentist’s objective assessment of esthetics could realistically include, for example, a Bioform shade 100 or a Bioblend shade 59.

The elements of patient autonomy and oral function are also effected by the patient’s subjective and the dentist’s objective judgments about esthetics.

Appropriate Oral Function/ Patient Autonomy

The dentist is permitting Mr. Davies to exercise his autonomy with his selection of the tooth color for his complete dentures, but is the dentist merely the agent who fulfills patient requests and is, therefore, free of responsible clinical decision-making?

Patients may have a diminished autonomy when they are in pain or have compromised oral function and esthetics. The edentulous patient has suffered a loss just as patients who suffer the loss of another body part and must adapt to a prosthesis, and some argue “no prosthetic restoration, even if mechanically and esthetically perfect, can restore a person’s image of himself as a whole person with no parts missing.”⁸ Most patients adapt to complete dentures and some even welcome the treatment. Even if they do adapt, they may feel, however, as one patient said: “the denture fits, I am not suffering any physical pain but part of me is gone. These are not mine; they are a dead part of my self.”⁸ When teeth are lost, “people lose more than function; they suffer a psychological shock that leaves them with a loss of self-esteem and other anxieties,” and some patients “may remain in a state of grief or depression in definitely.” ^5,8 The edentulous patient may feel as physically and psychologically vulnerable during a dentist’s oral examination as during a physician’s physical examination. One patient expressed the pain of seeing herself without dentures by saying “it just ripped my whole self apart. I felt I was old… it was absolutely ghastly!”⁹ Psychologists describe the edentulous patient as potentially maladaptive (the patient that views tooth loss as a serious impairment of the quality of their lives). As a result, the patient may pretend to seek technical advice from dentists when he or she may be actually seeking emotional solutions.¹⁰

Although Mr. Davies’ choice may seem misguided, even foolish, he has not asked for a treatment that is harmful or will compromise his appropriate oral function. Philosopher D.T. Ozar has ranked value categories in clinical dental ethics to establish a hierarchy that compares conflicting values in an ethics case.⁷ Ozar reasons, for example, that “accepting a trade-off which would leave a patient with significantly impaired oral function, even for the sake of autonomy… would be unethical practice.” If Mr. Davies’ brother requested, for example, full mouth extraction of his healthy, natural, objectively esthetic dentition so that he would feel “younger and more vigorous,” his request would not override the dentist’s responsibility for making a clinical judgment and determining if the treatment would significantly impair the patient’s appropriate function.

Respondents to the case chose to involve Mr. Davies in the treatment decision^11,12 by honoring the patient’s shade request at the wax trial denture appointment. One recommendation was to prepare a second wax trial denture based upon the dentist’s choice so the patient could compare the two. None of the respondents chose the paternalistic option to only show Mr. Davies a limited range of shades reflecting the dentist’s choice. Respondents also advised that persons whose opinion the patient respected have the opportunity to view the wax trial denture at the office, or some other convenient place. Involving Mr. Davies in decision-making prompted one dentist to write, “an educated, fully-informed patient is our best ally in determining the most satisfying smile makeover.”

Conclusion

When patients request esthetic dentistry, the subtle considerations of objective and subjective esthetics and the elements of respect for patient autonomy and preserving appropriate function must be considered in each case. Although Mr. Davies’ subjective request may not be congruent with the dentist’s more objective judgment, in cases where appropriate function is not compromised, the dentist should attempt to educate the patient about these differences but is justified in deferring the final judgment to the patient.

References

1. Kass, L. Practicing ethics: where’s the action? Hastings Center Report 1990; 20(1):5-12 at 7.
2. Nash D A Professional ethics and esthetic dentistry. J Am Dent Assoc (Special Issue) 1988:7- E.
3. Halperin AR, Graser ON, Rogoff GS, Plekavich EJ. Mastering the Art of Complete Dentures. Quintess, Chicago 1988.
4. Williams J L. A new classification of tooth forms, with special reference to a new system of artificial teeth. Dent Cosmos 1914; 56; 627-628.
5. Murrell GA. Esthetics and the edentulous patient. J Am Dent Assoc (Special Issue) 1 988:57 – E.
6. Lamb DJ. Problems and Solutions in Complete Denture Prosthodontics. Quintess, Chicago 1 993:91.
7. Ozar DT, Schiedermayer DL, Siegler M. Value categories in clinic al dental ethics. J Am Dent Assoc 1988; 188(3): 367.
8. Friedman N, Landesman HM, Wesler M. The influence of fear, anxiety, and depression on the patient’s adaptive responses to complete denture. Part I, J Prosthet Dent 1 988; 59:46.
9. Friedman N. Landesman HM, Wes le r M. The influence of fear, anxiety, and depression the patient ‘s adaptive responses to complete denture. Part II. J Prosthel Dent 1988; 59:46.
10. Friedman N. Landesman HM, Wesler M. The influence of fear, anxiety, and depression the patient’s adaptive responses to complete denture. Part III. J Prosthet Dent 1988; 59:173.
11. ADA Principles of ethics and code of professional conduct. Jan 1994.
12. Kawabe S. Kawabe’s Complete Dentures. Ishiyaku EuroAmerica, Inc. St. Louis. 1992:97.