Risk Management: 
Risks in Cosmetic Dentistry
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Dr. Rasetto offered an equally informative presentation, based on his extensive experience as both an educator and practitioner. 

“What,” he asks, “distinguishes a great cosmetic dentist from the dental pack?”  S/he needs an “excellent brain” (be knowledgeable in the latest dental procedures, products, etc.), excellent communication/people skills; and artistry coupled with creativity: intangibles that often “come from the heart,” and can’t be learned. “Artists are born, not trained,” he adds.

He continues, “Cosmetic dentistry is an illusion of nature (it must look natural).” That’s often a tall order for dental professionals.

“A natural look” is the caveat. Consider, for example, the restraint that must be exercised with teeth whitening. As Dr. Conrad noted earlier, today’s market demand is for whiter and brighter teeth.  Patients are requiring a whiteness that can’t be found on existing whiteness charts. These folks need to be educated that whitening outcomes will depend upon a variety of factors, including previous dental work, the materials used in previous work, the age of the work, etc. And the field of available whitening options is increasing, often pitting proper dental care against over-the-counter, less-expensive alternatives that may cause potential harm to a user’s dental and oral health in the future.    

Dr. Rasetto warns there is the practical, ethical side of cosmetic dentistry for which to account. Where managed care limits choices and decisions (such as the use of “best” materials, the kind of procedure proposed, the extent of the proposed intervention, etc.), it is the dental provider’s obligation to discuss all the options with the patient and give him/her the chance to go with the managed care decision or to go with your professional recommendation based on the patient’s overall health, expectations, etc. where the patient may – more than likely -  incur additional financial liability for the treatment(s).

“It is the dentist’s responsibility to fully understand the patient’s expectation and then lower that expectation if circumstances indicate the expectation is unreal or improbable,” he admonishes. 

Continuing, Rasetto opines, “The dentist is at fault is he fails to make all circumstances/findings available to the patient … irrespective of the patient’s ability to pay.”

What do you do if the procedure doesn’t yield positive or long-lasting results that either you or the patient anticipated? He cautions, “beware of patients with a ‘strong personality’ who dictate what they want in treatment based on their own research on a given condition on the internet. These folks fail to appreciate that treatment of a single tooth (or several teeth) often requires taking into account the condition of all teeth and the mouth in general.” Patients must understand that often, in order to address their dental needs, the treatment protocol actually will make things worse before they improve. Consent forms cannot replace a complete, thorough documentation in the dental chart of the informed discussion before any work begins.  “Complete documentation is the imperative,” said Rosetto.

And he warns:  “Face it … patients lie. They may not be totally up-front about lifestyle habits potentially affecting medical and dental health. For example, how many patients will willingly admit to meth use?” 

So he asks:  “What kinds of personalities do your patients have?”  He details the four personality types typically found in dental patients: the philosophical, the exacting, the hysterical and the indifferent.  Which type is most inclined to sue? The hysterical.

Critical steps a dental provider should follow in striving for successful treatment outcomes include expected results that are practical, reasonable, sensible and achievable; a written diagnosis, written treatment plan, prognosis and full informed consent; wherever possible, use of images for the proposed treatment and incorporate software treatment predictions. Likewise, limit creating false expectations by visualizing potential problems before they actually occur and anticipating and educating your patient regarding possible complications. Consider this example:  you know the risk for incurring a root canal in bridge work is about 3%.  Let the patient know beforehand the potential for the additional cost of a root canal, so in the event this occurs, the patient is neither surprised nor angered by incurring the additional expense.

And wherever practical, make use of the technological advances in CAD – computer-aided design – and CAM – computer-aided manufacturing.

Use wax-ups predicated on the “wisdom of working backwards”: propose the final product and then create the road map for getting there.  A wax-up will provide the patient with a reasonable idea of the end result of planned dental interventions.

There was plenty to take away from this meeting, but these are some of the highlights. So remember …

… the next time you go to your barber or hairstylist, think about your expectations for a coif. What’s the worst that can happen?  You don’t like the “do,” your hair grows out and you find a new barber or stylist! 

But keep in mind your unrealized expectations when next you encounter your dental patients. Be mindful of anything and everything that will be helpful in understanding their desires. Reframe and moderate those desires into a plan that is reasonable and acceptable to both of you and document everything. Documentation is still your best defense. Otherwise, you may be in for a painful and expensive situation with a dissatisfied patient.