It is strange, is it not how one remembers the tiniest details of some things but forgets large chunks of others? My early introduction to dentistry was through our family dentist who invited me to spend a day in the practice during my school holidays as I had decided to write about the subject for a project. In my early teens it was a very enlightening few hours but I recall being very struck with one of his pearls of wisdom that, in a course of treatment, it was always wise to complete the posterior work before the anterior restorations otherwise there was a danger that the patient would not come back. As a well brought-up young man I was shocked to think that people would do such a thing and that they would care more about their appearance than about their health.

Life has taught me otherwise in the intervening years but I was prompted to the recollection by a paper in this issue regarding the positive psychological benefits of implant mediated prosthodontic restorations in the anterior zone.1 Undertaken in China, the results of the study indicate that the desire to have a good appearance is not constrained by national boundaries or even culture but is a human need. That is not to say that cultural and social influences are without impact on oral health decisions. We have all had prosthetic patients, often elderly ladies, who request the lightest, whitest shade possible for the teeth on their 'new dentures'. As clinicians this makes little sense to us at all since the colour will scream out that the teeth are false every time the owner smiles. But that of course is the point. In the social circle in which the patient lives the status is raised by the very fact that they can either afford, or at least have the access to be provided with 'new dentures'. While to us the failure of oral health that this represents might be paramount and might best be disguised with teeth of a more natural hue for a person of those years, their motivation is entirely different.

British teeth

I would suggest that a similar, if less extreme example is true of our, that is British, overall preference for natural teeth and for ageing gracefully rather than for bright white Hollywood smiles. The adjective captures it precisely. For us the ear-to-ear veneered or crowned panorama is demonstrative not necessarily of health but of wealth, or lifestyle; it is a smile which our family and colleagues would view with some suspicion. Not that this precludes a good smile nor necessarily a whitened smile, only that it is not culturally regarded as a must-have. Conversely, we are chided by our American cousins for having 'British teeth' as Ricky Gervais recently found out after hosting the Oscars, as being less than sparkly-white and well, er, artificial.

The recent correspondence in the BDJ over the role of cosmetic dentistry also reminded me of my early days with the family dentist at which time a huge debate was in progress as to whether cosmetic dentistry should be allowed on the NHS. While one does have to consider that the discipline was in a far less developed stage, consisting primarily of porcelain jacket crowns and silicate restorations, I think it is fair to say that there was a general consensus that health should take precedence over beauty if the state is paying. However, the strength of feeling that has been expressed in these pages in the past few months has been surprising given that historically as a profession we have been happy wielding air rotors and cutting hard tooth tissue. Again, conversely, the realisation that minimal intervention is a logical and efficient way forward has been driving many techniques and philosophies, themselves made possible by the remarkable developments in materials.

As disease trends tilt away from caries in particular, and, crucially, as the expectations of our patients also change, so too will our modes of practice need to alter to accommodate not only health (or absence of disease) but also the presence of good looks and of well being. We are all aware of the positive psychological benefits that we generate for our patients by using our skills, often incorporating those of our technician colleagues too, by creating beautiful and appropriate smiles at whatever age our patients may be.

On the face of it, a move away from treating disease towards making people look and feel better can be a threatening prospect. Yet incorporated within this shift are potentially many of the directions that our recent and current content has been highlighting; minimal intervention, attention to the Adult Dental Health Survey, questions on the veracity of interventive cosmetic dentistry and the possible rise in the role of dental physician rather than the dental surgeon. These can be and should be exciting opportunities to ponder on, plan for and eventually take advantage of.