Gordon Christensen has raised this question for all dentists in his article "I HAVE HAD ENOUGH!", but particularly dentists who specialize in cosmetic dentistry. When is cosmetic dentistry ethical and when is it not ethical?

The bubble is going to burst on dentists who have limited their practices to cosmetic dentistry.

In 5-7 years there will be many angry patients who have cosmetic dental work that has failed or is failing. All dental work fails and cosmetic work fails faster than other restorative dentistry.

Even though the dentist has told the patient in every way he or she can that the cosmetic dentistry will wear out, most patients will not hear that statement. They will blame the dentist for the failure. However, the ultimate sin is not that the dental work failed, but the dentist failed the patient in not communicating, diagnosing and treatment planning properly.

Only do cosmetic dentistry as a result of a patient's informed request or when it is associated with breakdown of the teeth or past dental restorations.

The bubble will burst sooner for all dentists who unethically sell cosmetic dentistry to their patients. This will lead to disaster for these dentists and their patients.

Cosmetic dentistry is the most discretionary procedure in dentistry. When the economy goes in to a stall or decline, discretionary dentistry will be the first thing that patients elect to not do or postpone. Or when word reaches the media or lawyers that there is a problem with cosmetic dentistry, those dentists who unethically sell it will be in trouble.

While the dentist that has hung his or her hat on cosmetic dentistry is sitting at their desk looking at white space in their appointment book, the wise dentist that has resisted the temptation to "specialize" or sell will be busy doing remedial, maintenance and complete dentistry. The goal of this type of dentistry is to maximize comfort, function, health and esthetics.

What to do?

Resist the siren call of cosmetic gurus to limit your practice to esthetics. Only do cosmetic dentistry as a result of a patient's informed request or when it is associated with breakdown of the teeth or past dental restorations.

Collaborate, co-diagnose, consult, coach, facilitate instead of selling.

Henry Tanner said to only do TMD treatment at the patient's request. I think this applies even more to cosmetic dentistry. If the patient requests or insists on treatment, they feel more responsible for the outcome. If the dentist sells the treatment, the patient perceives the outcome as the dentist's responsibility.

Remember the occlusal principles when doing the treatment.

Be sure to inform the patient of all consequences of doing the cosmetic dentistry. Do not sell cosmetic dentistry. Document this clearly and have the patient sign an informed consent statement.

When cosmetic dentistry is done under these guidelines, it is ethical.

Be a decathlon dentist as Bob Barkley recommended, not a single event cosmetic specialist. Yes, there are dentists who have done well in cosmetics but there isn't enough demand for cosmetic dentists for large numbers of dentists to specialize. Most of these cosmetic dentists will bear the brunt of the patient's displeasure as their cosmetic restorations fail or they realize the dentist did not have their best interests in mind.

Keep cosmetic or esthetic dentistry as part of a h/c/relationship-based dental practice that offers complete dentistry with the goal of maximum comfort, function, health and esthetics.

Gordon Christensen's article "I HAVE HAD ENOUGH!" can be accessed at www.dentaltown.com. Go down to "select past issues" in the left hand column and enter September 2003. Click go. The article is second on the page.