Introduction

Why do patients attend dental practices? Sometimes it will be as an emergency with a specific outcome in mind, or for a routine assessment as to the state of their teeth, gums and mouth. In more recent times, however, an increasingly common reason for a visit has been for improvements in the appearance of the teeth and surrounding soft tissues of the face, together with the replacement of missing teeth. Whereas the specific outcome for an emergency visit is quite easy to define, as shown in Table 1, the routine dental check-up and the demand for cosmetic changes pose greater challenges to the practitioner in terms of the examination, diagnosis and care planning. Rather than focus on one issue, the practitioner must acquire a lot of information about the current status of all the hard and soft tissues and then decide how to manage any deviations from the normal.

Table 1 Common emergency situations presenting to the dental practitioner
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When presenting for a routine dental 'check-up', patients are effectively asking us, as their dentists, the following questions: 'how are my teeth?'; 'is my mouth OK?'; 'is there anything wrong?' or variations on these themes. These are, perhaps, the most difficult questions we must deal with as practitioners. How do we answer these? What criteria do we apply when replying OK or not OK! Healthy or not healthy! As dentists and dental health professionals, we are conscious of the need to promote and achieve oral health but quite what this means practically for individual dentists and their patients is very variable. In dentistry, as one of the caring professions, we offer our skills and expertise to improve the quality of life of others. However, there are limitations placed upon dentists by the General Dental Council (GDC) in their Scope of practice document.1

Oral health means much more than healthy teeth

In 1948, the World Health Organisation (WHO) expanded the definition of health to mean 'a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.' This places oral health as a fundamental component of health and physical and mental wellbeing.2

Glick et al.3 define oral health as: 'multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex. It is a fundamental component of health and physical and mental wellbeing. It exists along a continuum influenced by the values and attitudes of people and communities. It reflects the physiological, social and psychological attributes that are essential to the quality of life. It is influenced by the person's changing experiences, perceptions, expectations, and ability to adapt to circumstances'. Welie4 differentiates between treatment and enhancements, considering enhancements as 'the continuation of medical treatment proper beyond the "zero -level" of health whereas medical treatment is aimed at undoing "negative" conditions - diseases, illnesses, handicaps, pain, sickness etc - that violate the patient's integrity (health)'.

The challenge of accurate observation

It is self-evident that a full and accurate assessment of the soft and hard tissues in and around the mouth can only be made if their status can be determined. It is, therefore, essential to know what the normal appearance looks like in order to distinguish this from the abnormal, diseased appearance. Visual and tactile observations are only applicable to those structures that are readily accessible, whereas those beneath the surface can only be assessed by additional investigative procedures such as radiographs, cone-beam computed tomography, sensibility tests and biopsies. It then becomes possible to perceive two levels of answer to the question 'how is my mouth?' One answer will be based on an assessment of the superficial structures and surfaces which are directly visible (for example, teeth, periodontal tissues, soft tissues) and one will be based on an assessment which also evaluates the deeper tissues and structures. However, even within the visual assessment, there are two levels of observation: with the naked eye and with magnification. Experience shows that enhanced vision of carious lesions, restoration margins and tooth fractures aids diagnosis and there is ample evidence that magnification improves operative procedures.5,6,7,8,9,10,11

In Figure 1, the explanation for this symptomatic lower left first molar, with a periapical radioluscency, could only be found after microscopic examination in situ revealed fractures extending along the root. Extraction was required.

Fig. 1
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a, b) Asymptomatic lower left first molar with periodical radiolucency and microscopic fractures extending into the roots

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Effectively, this is the difference between looking at the screen of a mobile phone or a that of a large television. The challenge arises as to just how extensive investigations should be in order to be able to say to a patient, with a reasonable degree of confidence, that all is well. Should there be, in the absence of symptoms or clinical signs, an assessment of every tooth - its vitality, its periapical status, its supporting bone - in order to be able to report to the patient, with a high degree of certainty, the status quo? Without further investigations there will be a presumption of health in the deeper tissues and structures as opposed to a knowledge of health (Fig. 2).

Fig. 2
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The interaction between the dentist and the patient. Reproduced from Robert Caplin, Grey areas in restorative dentistry - don't believe everything you think!, J and R Publishing, 2015

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For the 23-year-old patient in Figure 3, presenting for the first time and requiring a 'check-up' with no visible signs of carious enamel or dentine, a decision must be made as to whether bitewing radiographs are required or are desirable and whether any other further investigations would be warranted.

Fig. 3
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a, b) Clinical appearance of upper and lower teeth without obvious carious lesions

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However, there would probably be general agreement about the need for further investigations for the patient in Figure 4 and yet, the information required is the same as in the patient mentioned previously; the need to know what is going on in unseen areas.

Fig. 4
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a, b, c) Clinical appearance of upper and lower teeth with damaged and missing teeth

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In the first patient, there would be a presumption that in the absence of clinical signs there will be healthy roots and bone; a presumption but not knowledge! This highlights the dilemma that all health professionals face - that in order to obtain as much information as we can about the status of the tissues, we do not unintentionally contribute to the medicalisation of society with investigations that do not alter care plans.

While there is no consensus on which radiographic views should be used in any given situation, the Faculty of General Dental Practice UK12 addresses this issue and one approach favoured by Caplin13 is the radiological examination of all teeth with indirect restorations or large direct restorations.

Figures 5 and 6 show periapical radiolucencies picked up on routine investigation of asymptomatic crowned teeth. These would not have been detected by visual and tactile examination alone.

Fig. 5
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Long cone periapical radiograph of asymptomatic 26 with apical periodontal membrane widening

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Fig. 6
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Long cone periapical radiograph of asymptomatic 22 with a periapical radiolucency

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Asymptomatic periapical lesions

Perhaps the most common asymptomatic unseen disease process in the mouth is that occurring around the apices of teeth. Huumonen et al.14 point out that the diagnosis and management of periapical lesions requires a thorough clinical and radiographic examination.

It has been shown that pathological processes within cancellous bone do not show on the standard view because of the density of the overlying cortical plate of bone. Only when some of the cortical plate has been lost will the lesion become apparent, but even then, the lesion will generally be larger than it appears on the radiograph. The practical implication of this is that many teeth may have asymptomatic periapical lesions that have not been detected by the examining dentist. Furthermore, it has been shown that asymptomatic periapical lesions may exist around the apices of teeth but not be visible on periapical radiography. Can we genuinely say whether the patient is healthy or not?15 This is the challenge of clinical decision-making.

Had these radiographs not been taken, the examining dentist would not be aware that there was a disease process around the apices of the teeth and so could have advised the patient that all was well and healthy, when in fact, this was not the case. What should be relayed to the patient and whether there should there be active intervention moves on to the next phase after the examination, which is clinical decision-making.

Clinical decision-making/judgement

With a wide range of clinical situations presented to the dental professional and the wide range of options available to manage these, the clinician must exercise clinical judgement, that is, clinical decision-making within the context of the patient.

Decision-making is a broad term that applies to the process of making a choice between options as to a course of action. Clinical decision-making/reasoning is the process used to make a judgement about what to believe and what to do about the symptoms and signs that a patient presents with to enable a diagnosis to be made and treatment options considered. Facione and Facione16 considered clinical reasoning as a process 'that in order to arrive at a judgement about what to believe and what to do, a clinician should consider the unique character of the symptoms (evidence) in view of the patient's current health and life circumstances (context), using the knowledge and skills acquired over the course of the health sciences training and practice (methods, conceptualisations), anticipate the likely effects of a chosen treatment action (consideration of evidence and criteria) and finally monitor the eventual consequences of delivered care (evidence and criteria)'. Trowbridge et al.17 extend this by seeing clinical reasoning not only as a conscious process but with the healthcare worker also interacting with the patient and the environment at an unconscious level. Critical thinking, defined by The American Philosophical Society18 as 'the process of purposeful, self-regulatory judgement which gives reasoned consideration to evidence, contexts, conceptualisations, methods and criteria', shows how this process is integral to clinical reasoning and decision-making.

The challenge is to arrive at a care plan that is appropriate for the patient, meeting their needs and expectations and at the same time, not compromising the ethics and morals of the practitioner. The care plan for a young adult with a high plaque score, several bleeding sites and several new sites of carious enamel and dentine might be quite different for an older patient with a similar clinical situation but with multiple health problems, inability to undergo lengthy procedures in the dental chair and lack of manual dexterity. A defining time in the relationship between the dental practitioner and the patient came with the publication of Standards for the dental team by the GDC.19

Within this document is a requirement to 'give patients the information they need, in a way they can understand, so that they can make informed decisions' and 'make sure that patients (or their representatives) understand the decisions they are being asked to make'.

A landmark decision by The Supreme Court of the United Kingdom finally ended medical/dental paternalism. In the case of Montgomery v Lanarkshire Health Board, it was established that, rather than being a matter for clinical judgement to be assessed by medical (dental) opinion, a patient should be told whatever they want to know, not what the health professional thinks they should be told.20

This requires honesty by the practitioner about the risks and benefits of any proposed treatment or alternatives and the option not to do anything.

The challenge of disease management

With the current approach within dentistry of prevention and minimal intervention for the management of dental disease, the dental practitioner faces the challenge whether to monitor or treat diseased tissue and whether a cure is either possible or desirable where cure means a complete restoration of health.21 Treatment, on the other hand, refers to a process that leads to an improvement in health but may not include the complete elimination of disease.22 There are, indeed, several measurable aspects of disease and their initiating factors, such as plaque and bleeding scores, tooth mobility and tooth surface loss. How much of this information should inform the clinical decision-making will follow a full and frank discussion with the patient of the risks and benefits of any intervention proposed, alternative options and finally, the option not to do anything. Huber et al.23 make the point that the requirement for complete health would leave most of us unhealthy most of the time and that health should be seen not as a static state but a more dynamic one, based on the resilience or capacity of the individual to cope, that is, to adapt and self-manage.

Although caries, periodontal disease, broken teeth, missing teeth, etc are deviations from the normal, the philosophy that it is essential to restore to what was 'normal' is questionable. It is essential to weigh the benefits of treatment against the risks and to consider the long-term implications of any interventions. Caplin24 uses a similar situation to Figure 7 as an example of the range of options available to patients in any given clinical situation, with a range from no intervention to the extensive further tooth tissue loss of providing a crown.

Fig. 7
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Gross hard tissue loss

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The practitioner is, in effect, being asked to predict the future and to decide what would be the most acceptable way to deal with a tooth so that it lasts as long as possible. Restoring it is not necessarily the fall-back position as treatment can inflict more distress on the tooth and its supporting structures.

A state of complete physical, mental and social wellbeing

Most criticism of the WHO definition of health2 concerns the absoluteness of the word complete in relation to wellbeing. The problem is that it unintentionally contributes to the medicalisation of society. According to Smith et al.,25 'the requirement for complete health would leave most of us unhealthy most of the time because it lowers the threshold for intervention, inviting treatment for abnormalities at levels that might never cause illness'. Tinetti and Fried26 are concerned that 'the emphasis on preventing and treating individual diseases leads to overtreatment', an issue shared in dentistry according to Holden.27 They suggest that clinical decision-making should be predicated on the attainment of patient goals and on the identification and treatment of modifiable biological and nonbiological factors, rather than on the diagnosis, treatment, or prevention of individual diseases.

They see the patient's complaints as generating three questions by the practitioner to whom they go for care:

  1. 1.

    In what ways are the complaints bothersome - what is the effect on the patient's physical, psychological and social functioning?

  2. 2.

    What does the patient hope to achieve from medical (dental) treatment? What trade-offs is the patient willing to make? In the case of prevention, does the patient value 'down the road' benefits more, or does the patient have more immediate concerns?

  3. 3.

    Are psychological or social factors further impeding health and functioning?

The challenge for the dental practitioner is to be sure that irreversible procedures are only undertaken when the patient's answers to all these questions have been thoroughly assimilated and the care plan discussed with the patient.

Replacement of missing teeth

Although more obvious in the aesthetic zone, the request for the replacement of missing teeth more posteriorly may stem from a perceived loss of chewing function. Although nature provides us with 32 teeth (most of the time), the loss of posterior teeth should not automatically lead to their replacement. The shortened dental arch concept accepts a reduced number of naturally interdigitating units, thereby reducing the need for their prosthetic replacement with the subsequent morbidity that a prosthesis or implants can produce. Patients can and do manage without the full complement of natural teeth. In these situations, the patient can still be considered as functionally healthy.28 But what if the patient is adamant that the missing teeth should be replaced?

Should we meet the patient's request?

As health care providers, embracing the emotional and psychological wellbeing of our patients places an additional burden on the route to successful dentist-patient outcomes. Are we healing and/or enhancing those who come to us for care? Furthermore, in the absence of clinical need, should we be informing those who come to us for care of treatments that could potentially change (improve) the patient's smile? This dilemma is highlighted in Figure 8. Clinically, the margin of the restoration at the upper right central incisor is intact; no carious enamel or dentine is detectable; the tooth has a satisfactory root-filling; and the patient does not mention the appearance of the tooth. Some feel strongly that aesthetic dentistry should be included as part of the recommendation in the care plan.29

Fig. 8
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Tooth 11 with clinically satisfactory restoration

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If in clinical practice the dental professional embraces the quality-of-life concept (the degree to which a person enjoys the important possibilities of life)30,31,32 and applies the definition of oral health, it could be concluded that the practitioner is thereby challenged to undertake any treatment that the patient feels will improve their life. Can the practitioner reasonably refuse the patient's request assuming it to be legal and ethical? However, it should be remembered that the practitioner has a choice and even though a patient has autonomy, their wishes are not absolute and binding on a practitioner. The dentist has the legal right not to provide a certain procedure if it is considered that it will not benefit the patient or even harm the patient (non-maleficence).

The 'Daughter Test' can be a very powerful influence in planning decisions.33 At its simplest, in relation to elective aesthetic dentistry, is the question: 'knowing what I know about what this procedure would involve to the teeth in the long term, would I carry out this procedure on my own daughter (or any other close relative)?' Morals, values, culture and philosophy will influence each individual practitioner.

The challenge of enhancing

The area of dentistry concerned with the 'improvement' of the appearance of teeth and soft tissues presents enormous challenges to the practitioner. Who is it that decides what looks good or acceptable - the patient and/or the dentist?

For the female patients in Figures 9 and 10, gold crowns were desirable and a socially acceptable appearance when they were young (before preparation, the teeth were intact and healthy). In their thirties, both bitterly regretted having had these crowns. Was this appropriate treatment? Whose interests were being served?

Fig. 9
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Gold crowns provided on intact healthy teeth

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Fig. 10
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Gold crown provided on an intact healthy tooth

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Dentistry may be defined as 'the art or profession of a dentist'34 and as such, dentistry can be more subjective than objective and more of an art than a science,35 although the practitioners should always conduct themselves as professionals. In the context of enhancements, it is important to understand what being a member of a profession means and the challenges that it presents.

A profession is 'an occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society'.36

The applicability of this definition is challenged by Welie,37 who concludes that whereas dentistry qualifies as a profession, it is also exhibiting a trend to again become a business, as it was before the nineteenth century. He points out that 'not every treatment performed by dentists is aimed at relieving serious pain or threat to the patient's health. Indeed, more and more of the treatments now performed by dentists are cosmetic interventions. However, ugliness is not a medical indication; it does not necessitate medical treatment in the same way that a toothache, gingivitis, or oral cancer does. Dentistry does not qualify as a profession when and to the extent that the interventions performed are purely elective instead of medically indicated. It therefore behoves dentists who focus their practices on aesthetic interventions to clearly state that they are not professionals'. This view anticipates the morphing of the relationship between that of the dentist and patient to that of dentist and consumer.

As patterns of dental disease show decreasing levels of dental caries in many parts of the world,38 it is unsurprising that dentistry is viewed increasingly as a commodity.

Professionalism versus commercialism

The incompatibility of these two approaches is articulated by Lyons39(see Table 2).

Table 2 Commercialism versus professionalism
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Additional recognition of the conflict of values comes from Holden:40,41 'the professional ideals that the dental profession would seem to support and promote, contrast sharply with the values of the commercially driven consumer society; the same society that the profession states it serves without self-interest. The introduction of mental and social wellbeing brings into focus the aspect of enhancing or cosmetic dentistry and the implication that this has for the relationship between the dentist and the person coming for care, from patient to consumer. The dentist is no longer being asked to deal solely with the effects of dental disease but to deal with the flawed smile'. He concludes that 'cosmetic dentistry is undeniably part of the professional purpose of twenty-first century dentistry' but cautions that 'this is conditional upon the professional conduct of dental practitioners remaining resilient to commercial practices not compatible with professional obligations'. The obvious challenge for all undertaking this type of clinical work is to retain the barrier between being a professional or a commercialist.

Conclusion

The routine dental examination and the subsequent formulation of a care plan present the dental practitioner with several challenges. The practical challenges in accurately assessing the state of the hard and soft tissues, the care planning challenges in the management of deviations from the normal, and the ethical and moral challenges of meeting the desires and expectations of patients. There is a tension between the demands of the patient and the recognition by the practitioner of the need to aim for oral health, as well as the preservation of healthy tissue. Often, these may be diametrically opposed. Since most aesthetic procedures carried out in dentistry are within the private sector and hence subject to financial negotiation, there is the ever-present risk that the decision-making process by the practitioner will be highly susceptible to financial consideration: 'money corrupts the process of reasoning'. The practitioner must be alert to this and be aware of whose interests are being served when undertaking any procedure but especially so when aesthetics/cosmetics are the driving force.

Where the elimination of existing disease may not be possible or desirable, the practitioner has to decide at what point intervention should take place. How much disease to accept should be based on a thorough understanding of the person who has come for care and their attitude to their mouth, as well as the desire or the ability of such a person to attend on a regular or frequent basis in the future in order to maintain health.

What should the response be to the implied question - how is my mouth? This can only be answered honestly after an accurate assessment of the hard and soft tissues has led to clinical decisions that incorporate an understanding of the needs and wants of the patient. Fundamentally, dentists should enhance the lives of those that come for care. We want our patients to be free from pain, to be able to chew and speak well, to be comfortable with their appearance, to feel good about their mouths and to have the knowledge and understanding to maintain their mouths in a healthy condition. The best dentistry is no dentistry; to see or not to see; to plan or not to plan; to intervene or not to intervene - these are the challenges!