Article received on February 09, 2018 and accepted for publishing on May 28, 2018.
Ethical limits between aesthetic and cosmetic dentistry
Marina Melescanu Imre1, Elena Preoteasa1, Ana Maria C. Tancu1, Cristina T. Preoteasa1, Mihaela Pantea1, Paula Perlea1
Abstract: Esthetics is the “new trend” in dental medicine as a natural consequence of the development of modern society, with implications in practice and training. Like any rule in art, but also within the medical field, esthetics must be known and addressed in relation to other medical or non-medical principles (dental cosmetic), respect the ethics rules.
Aim. Literature study designed to focus on the current problems that modern dentistry is facing, in relation to esthetic requirements. The literature search strategy in electronic databases: EBSCO Data Base, Dentistry & Oral Sciences Source, Pub Med indexed articles, used Boolean Operators.
As a conclusion, the dentist must be familiar with the differences between esthetic and dental cosmetic, must minimize the subjective component of the examination, identify the reasons of presentation, guide the patient in choosing the optimal treatment, including obtaining the desired esthetic results, within the ethical boundaries of the noble medical profession.
Keywords: ethics, esthetics, cosmetic dentistry
INTRODUCTION
Nowadays, more and more frequently, within dental, practical or training activi- ties, we are dealing with matters related to esthe- tics. Patients often require esthetic restorations with- out being able to specify most of the time, what exactly they would like.
Students show an increa- sing interest in esthetic dentistry aspects.
As professionals we are flooded with an information influx both through scientific publications and dental materials producers, with a dental esthetics value.
After the implant, esthetics is the “new trend” in dental medicine as a natural consequence of the development of modern society.
Esthetic concerns existed since forever, from the first protagonist of scientific esthetics Pythagoras, who defined the “golden ratio”, combined with dynamic symmetry discovered in 1920 by Jay Hambridge and Sir D’Arcy Thompson who explained how natural beauty can be quantified and how it can be reproduced in art, architecture and other crafts.
For dentistry, as terminology, in the Glossary of
REVIEW ARTICLE
1 Faculty of Dental Medicine, University of Medicine and Pharmacy Carol Davila, Bucharest
Corresponding author: Ana Maria C. Tancu MD, PhD amctancu@yahoo.com
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Prosthodontic terms, esthetic dentistry is defined as the part which studies beauty, creating harmonious results through prostheses, and ethics is a moral principle or a set of moral values of an individual or group of individuals, in our case – the ones involved in the treatment (doctors, technicians). Cosmetic dentistry is not a term indexed by GPT, its definition being present in the Collins dictionary, like maneuvers aimed to beautify without purpose or functional form.
The medical profession has ethical obligations [1]
centered to prevent and treat diseases, in order to rehabilitate the dento-masticatory apparatus functionality, namely mastication, phonation, and the patient's physiognomy.
Questions related to dental esthetics are: What are the ethical boundaries of the esthetic trends in dentistry?
Can anything be done from a medical standpoint for the sake of obtaining an esthetic outcome? Are we ready for this new challenge as physicians who took the Hippocratic Oath for the “primum non nocere”
principle? Are we trained as trainers, academics, in order to educate students so that they become true professionals in esthetic dentistry? What are the limits of esthetic dentistry and dental cosmetic, as a new term in our vocabulary?
These are some of the questions that have led us to write this paper. This study is a literature one designed to focus the current problems that modern dentistry is facing in relation to esthetic requirements. The original aspect of this work is related to the definition (both for patient and doctor) of these two terms, their character being a little bit confusing, also being capable to lead to legal aspects, even malpractice.
MATERIAL AND METHOD
A comprehensive literature study was completed in October 2015. There were selected publications in English, peer reviews, articles from academic publications, dated January 2000 to December 2015.
There was obtained a total of 1248 articles, including full text criteria, of which 580 articles were retained, and after applying the selection criteria only 14 publications remained. Identified as directions of interest were: (a) dental esthetics as part of dentistry – boundaries; (b) the difference between esthetic and
dental cosmetic, from an ethical point of view; (c) esthetics, the reason for treatment and clinical examination; (d) medical training, scientific publica- tions, patient information, consent. The search strategy was conducted using EBSCO Data Base Dentistry & Oral Sciences Source with the aid of Boolean Operators. The following keywords were combined: ethics, esthetic, and cosmetic dentistry.
The search was limited to English peer reviewed articles, full text and years limitation January 2000 - October 2015 academic journals.
RESULTS
There was obtained a total of 1248 articles, including full text criteria, of which 580 articles were retained, matching the search criteria requested. After applying the search criteria 10 publications became relevant.
Furthermore, there was done a manually electronic search on themed websites. In the end, 14 publications that included the search criteria were selected. Among the issues raised by the retained publications, there were identified 4 axes of interest:
1. Dental esthetics as part of dentistry – boundaries.
2. Difference between esthetics and dental cosmetic from the ethics point of view.
3. Esthetics, as a reason for treatment and clinical examination.
4. Training the physicians, scientific publications, informing the patient – consent.
DISCUSSION
Dental Esthetics as Part of Dentistry – Boundaries At this point two issues detach themselves – functionality and bias. As noted in the introduction, there is a definition of dental esthetics in the GPT, however this is rather vague, making reference to
“beauty, following the art’s rules and principles''. In dentistry, the therapeutic dental restorations are not only esthetic, but they should primarily ensure the dento-masticatory apparatus and the dental occlusion functionality. For example, dental fillings can be done medically with physiognomic or non-physiognomic materials, both having advantages and disadvantages,
the dominant criteria for the physician must be based on clinical experience, choosing the optimal method of treatment in order to meet the basic medical principle,
“primum non nocere”. [2]
The medical profession bases its treatment on clinical, objectively examination of the patient. When regarding the esthetics dental problems, subjectivity might occur; hence, the need to establish clear criteria, both objective and subjective, for the examination in dental esthetics. Indeed esthetic sense is not a criterion for graduation from the Faculty of Dentistry;
it has a great variability from person to person, from clinician to clinician, as well as from patient to clinician. Given these difficulties related to the subjective issues, it was suggested a hierarchy of the esthetic aspects in dentistry, starting from basic esthetic rules where the smile’s coordinates comply to the classical principles of the golden ratio, symmetry, dental and dento-facial proportions, smooth line smiling.
The next level is represented by the cultural and regional subjective aspects, for example in the United States the so-called Hollywood smile is a social standard, the whiteness and perfect alignment of teeth being associated with wealth, social and financial success. At last, the latest level is the so- called virtual level – the one that a computer program sets as ideal for the patient, from the esthetic point of view. [3]
Is dental esthetics a part of the patient’s general health state? Yes, it was clinically proven that the esthetic restoration brings an important psychological benefit to the patient. [3]
Difference between Esthetics and Dental Cosmetic from the Ethics Point of View
Within the last years, appearing the dental cosmetic term, that was medically not registered otherwise, there have been many misunderstandings between this term and the esthetic dentistry, both among patients and practitioners.
Traditionally, dental medicine as a medical specialty is centered, ethically speaking, on the prophylaxis and the treatment of the dental tissues in order to ensure
a good health state, respecting, of course, the dento- masticatory functions. So, we are talking about affected tissues, or with such potential. [4]
Dental cosmetic seeks only embellishment, often without any consideration for functionality, interfering with healthy tissues, without clinical impairment for beautifying intentions. Often, these maneuvers contradict even the esthetics concept – defined as being an integration concept of beauty in natural proportions, with a humane dimension. Is it esthetically the completely unnatural pure white smile of an 80 years old lady? Is it not against the physiological processes of aging teeth, with natural tooth staining due to time passage? Therefore, the difference between cosmetic and esthetic dentistry must be properly ethically and medically differentiated [5,6]. Moreover, some cosmetic maneuvers might damage a healthy dental tissue – for example when applying veneers, esthetic crowns, excessive grinding, applying adhesive – without pulp protection – can lead to tooth loss – defined as disfigurement, from the ethical point of view. [3]
One must respect, from the ethical point of view, the principle of minimally invasion; the so-called enamel sacrifice on the altar of vanity [7, 8, 9] does not correspond to the principles of medical ethics. On long-term, the biological implications of the maneuvers consequences that were performed only for cosmetic purposes should be correctly assessed by practitioners. [10] Esthetic would mean beauty, form and function – and cosmetic only beauty. [2]
Esthetics, as a reason for treatment and clinical examination
As shown, although the boundary between esthetic and cosmetic maneuvers may seem “too fine”
sometimes, the practitioner disposes of objective criteria when deciding the treatment plan. [11]
Patients who address the dentist for solving the esthetic problems divide into two categories – among these reasons are dental crowding, discoloration, unsightly tooth discoloration, missing teeth, multiple teeth with coronal restorations. The patients’ reasons may be esthetic ones, but after a properly conducted clinical examination, the dentist will establish the
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functional problems – occlusion problems, migration and others that, from an objective medical point of view, should be rehabilitated in order to restore the morpho – functional, esthetic, masticatory and phonetic balance. The dentist will decide the patient's treatment plan, single or multidisciplinary orthodontics (teeth alignment through braces), conservative treatment (bleaching, esthetic restorations, and ceramic veneers), and dental prosthetic (crowns coverage, dental implants). A second category refers to patients without enough arguments – patients suffering from narcissism, personality disorder, patients who can’t accept their age. As in the first group, the dentist is the one that will make a “proper diagnose” considering the medical history and clinical examination.
Patients with such presentation reasons will permanently be unsatisfied with the treatment outcome. Unlike the ones with consistent esthetical grounds that will be satisfied once the esthetic problem is solved, for the second class the result will not be acceptable even if it has improved the esthetic aspect. [2] These are the most common candidates for dental cosmetic, for whom the “primum non nocere”
principle must be respected from the ethical viewpoint. [10]
And not least, after the clinical examination, if the dentist is in a doubtful situation, he should, according to "when in doubt, it is probably not ethical" [7] test himself with "The Daughter Test" – Would I proceed with this intervention on my daughter? [8,12]
Training the physicians, scientific publications, informing the patient – consent
Another important aspect is the dentists training, in addition to the fundamental principles of dental esthetics already learned in college; the profession currently faces numerous specialty publications in which the so-called academic articles are praising esthetic results obtained – the ethical aspect of the presented cases being often questionable from the fairness of the dimension’s vertical occlusion point of view, occlusion stability and durability of these restorations. Publishing some insufficiently and superficially documented cases – medically speaking,
designed only to beautify, can be really dangerous, especially for young doctors who didn’t benefit from enough clinical experience and being pressured by patients in order to obtain esthetic results, can guide their therapeutic conduct, based on good faith. [10]
In the modern age, consumer society pushes dentists to features, such as advertising, with the temptation for many dentists to promise spectacular results with a negative impact on the professionalism of the entire profession [6], we must not forget the fundamental nature of our medical profession profile, namely the professional doctor [13] and not the beautifying one.
In this context it is important, ethically speaking, the doctor-patient communication regarding the dental esthetic issues – the doctor is required in this type of treatment to inform the patient in order to receive his consent over long-term implications (especially in younger patients). Communication must be made in terms that the patient will be able to understand (not necessarily medical terms), assisted by pictures, drawings, suggestive dental casts. It is also required to present to the patient, where appropriate, one or more treatment alternatives, including the less esthetic alternative, before signing the informed consent [3]. Esthetic dentistry requires less accommodation, incorporates acceptable biologic technology for long-term survival, functions suitably, and mimics the pristine state of the natural dentition.
Cosmetic and esthetic dentistry are different in definition, concept, and execution [14].
CONCLUSIONS
As a result of this extensive literature study on a very actual dentistry issue – ethical considerations of esthetics and dental cosmetic, we came up with some interesting conclusions intended to clarify the often encountered confusion regarding these terms. Dental Esthetics regroups several dental maneuvers, often interdisciplinary, aiming the morfo-functional rehabi- litation of the dento-masticatory apparatus, following universal esthetic principles harmoniously integrated into the overall health and harmony of the human body as part of dentistry. Dental cosmetic is a set of maneuvers that, although have a medical character, do not seek the reconstruction of the maxillary device
functionality, just have a beautifying character, intervening on healthy tissues without any prophylactic role, often with disabling long-term implications. In terms of bioethics, the “primum non nocere” principle is not respected within these maneuvers.
Therefore, it is important for the dentist to know the differences, the fundamental dental esthetic concepts, in order to minimize the subjective component of the examination, to succeed the clinical examination with identification of the presentations reasons, to be trained for all medium- and long-term treatment
implications, in order to be able to present to his patient all treatment alternatives and guide him to choose the optimal treatment option for obtaining the desired esthetic results within the ethical boundaries of this noble profession. The theme being new and the boundary between esthetics and cosmetic dentistry being quite subjective, no doubt that they still have to be studied, there are needed further studies and research that will clarify the differences between them on an evidence-based scientific system.
Acknowledgements
All authors had equal contribution in this paper elaboration.
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