Failed smile design

Sir, we would like to take this opportunity to add to the debate highlighted in Ethical issues in cosmetic dentistry by M. Kelleher (BDJ 2012; 212: 365–367) and show how failure of this type of cosmetic dental treatment can impact on a patient's life.

Our community dental service treats patients with moderate to severe special care needs. It is uncommon that we come across patients who demand 'ideal smile designs', as our patients generally have pressing complex social, medical and psychological problems to deal with. We were therefore surprised when this 26-year-old female, who is homeless with other complex problems, presented to us as an emergency patient seeking help with her veneers, which she complained 'would not stay on' (Figs 1-2). Further examination revealed 12 veneers extending from UL6 to UR6 of which five had failed. On questioning, the patient revealed that they were fitted less than a year ago, under sedation, and when the veneers fell off she re-cemented them herself with superglue. She was prompted to seek treatment as the layers of glue had become so thick that it was no longer effective and her poor appearance was causing her great distress, impacting adversely on her rehabilitation into society, and had increased her dental phobia.

Figure 1

A 26-year-old patient with failed veneers and multiple deep carious lesions

Figure 2

A 26-year-old patient with failed veneers and multiple deep carious lesions

Further investigation also revealed multiple deep carious lesions with potential pulpal involvement, a diet history of excessive sugar intake, including six spoonfuls of sugar in her tea, and the fact that she was in the early stages of pregnancy, ruling out the use of sedation to manage her dental anxiety.

Whilst a dentist cannot accurately predict the future potential health and personal issues that their patients may suffer from, we feel that before 'cosmetic procedures' are undertaken one should always consider what the consequence would be if treatment fails or the patient becomes unable to maintain it both financially and psychologically.

This case highlights the importance of a thorough social and medical history with a full caries risk assessment prior to any cosmetic treatment planning. We are now facing the challenge of achieving oral health for this patient who is currently very vulnerable and is under a great deal of stress, partly as a result of this failed 'smile design'.