Cosmetic Dentistry - What's it all about?

Surfing the net is great fun… until – *bash* – a wave hits you from behind. What the f*** is that?? Before and after pictures of someone with perfect teeth after… AND perfect teeth before??? You’ve landed on a cosmetic dental office website!

OK, I’m slightly exaggerating here… but especially if you live in the USA, you may come across websites which offer cosmetic dentistry to people who already appear to be blessed with perfect teeth. No need to feel (totally ;) ) inadequate – here’s the low-down on what cosmetic dentistry is about! “Cosmetic dentistry” is the branch of dentistry dealing with the appearance (rather than the health, although the two are obviously not mutually exclusive) of teeth. For example, “white fillings” can be considered cosmetic because they look better, but at the same time, they can also be “healthier” because they require less removal of tooth structure. And in complex cases, cosmetic dentistry can be a godsend, because other solutions which might be acceptable health-wise are simply not as good-looking or functional. “Cosmetic dentistry” encompasses all dentistry that’s not strictly necessary for health reasons, and much of it is a matter of personal needs, preferences, and opinions.

Aesthetic vs. Cosmetic Dentistry

A distinction can be made between aesthetic dentistry, which implies restoring teeth to their normal appearance as found in nature, and cosmetic dentistry, which is improving the colour, shape or arrangement of teeth to make things look better to the eye of the beholder, which often can mean “looks fake”. Ideally, all dentistry should be aesthetically pleasing especially where front teeth are concerned, i.e. you should look as good as or better than before treatment. Regardless of whether or not you are in favour of cosmetic enhancements (and there’s plenty of controversy about this also within the dental community) – if you have a dental phobia, all this talk about cosmetic dentistry can be a little spooky. After all, you’d be thrilled to bits if you could just get your teeth fixed… but no, seemingly that’s not enough… *sigh*… Hang on a second! Those websites might lead you to believe that dentists are out en masse trying to make big dollars (or pounds, or euros) by pushing people into “cosmetic dentistry”. And true enough, such dentists do exist:

“The initial “we love you and want to help you” feeling is being erased by “new charges” and “future cosmetic work”. The cynic in me says that the treatment of dental phobics is an open door for $h!t schmooze artists.”

Unfortunately, there is a good deal of truth in this statement which appeared on our forum. You may have noticed – while surfing the web for U.S. dental offices which cater to dental phobics – that a lot of them offer both sedation (touted as “the solution” to dental phobia) AND cosmetic dentistry. In fact, the two of them often seem to go hand-in-hand. Many of these sites will also use suggestive language to make you believe that you’re somehow inadequate, and will offer “smile assessments” along the lines of “Are you unhappy with ugly metal fillings showing when you laugh?” or “Are you embarrassed because your teeth are not white enough?”. It is easy to see what these “smile assessments” are trying to achieve: to make you think you have an embarrassing problem (which you may never have considered a problem before you read their questionnaire) and thereby attract more customers and make more money. It helps if you are aware of these tactics and can see through them! In all fairness, these types of “cosmetic dentists” are as of yet in a minority, in the U.K. at least. Most dentists who offer cosmetic/aesthetic dentistry do so as an additional service for those who are unhappy with their appearance and who specifically seek to improve their smile. Also, many dentists (both in the U.K. and in the U.S.) advertise themselves as providing “cosmetic dentistry”, even though what they really mean is that they are providing aesthetic dentistry. The reason why they use the term “cosmetic dentistry” is because that’s what people google for!

Just because a dentist promotes cosmetic dentistry doesn’t mean they are “bad” or that you should rule them out while searching for a dentist.

In practice, the aesthetic/cosmetic distinction is very blurry. The terms are interpreted differently even within the dental community – with some dentists referring to “aesthetic dentistry” when they really mean “cosmetic dentistry” and vice versa. So we’ll stick with “cosmetic” for now…

Examples of Cosmetic Procedures:

What’s the story with replacing amalgam fillings?

Replacing existing amalgam fillings with white fillings has its pros and cons. On the pro side, it looks more natural. Some cosmetic dentists would also argue that it reduces the chance of undetectable decay leading to a silent destruction of tooth structure until pain indicates the need for treatment, and that amalgam can expand over the years, possibly causing a tooth to crack. On the other hand, conservative dentists agree that every time you remove a filling, you remove a bit more tooth substance, plus you insult the tooth with more trauma. Every time you remove a filling and put another in its place, you run the risk of killing the nerve of the tooth and then needing more complex treatment. So having a lot of amalgam fillings replaced for cosmetic reasons may not be such a good idea after all. A filling should not be replaced unless it is damaged, broken, or has decay around the edges or underneath. Amalgam fillings can last for a very long time (some sources estimate 14 – 40 years or even longer – it’s not unusual for an amalgam filling to last a lifetime). So the very fact that you have a mouthful of them and haven’t seen a dentist in a while doesn’t mean they need to be changed. Amalgam has its advantages – for example, it tends to be self-sealing which means that amalgam fillings resist recurrent decay better than white fillings. A dentist should not replace fillings that don’t need to be replaced. If a dentist tells you that amalgam is toxic and should be removed, run. Martin Spiller DMD has a six-page essay devoted to this topic if you’d like to find out more: Are amalgam fillings toxic?

Should I have my teeth whitened?

Teeth whitening has caught on big time, and doesn’t appear to carry any major health risks. The most common side effect is temporary sensitivity in some people – if you have sensitive teeth, tooth whitening may not be much fun. The lower the concentration of the bleaching agent is, the less likely it is that there will be sensitivity. This means you’ll have to do it over a longer period of time. Teeth whitening tends to work best with a custom tray made by a dental professional. Beware – teeth whitening or bleaching will not lighten existing dental work such as white fillings, bonding, crowns, or bridges! Also, the bleaching isn’t permanent and you’ll have to re-do it every so often. So if you have bleaching done and dental work which matches the whitened shade, you will need to keep up the bleaching. In this case, bleaching will be a long-term commitment. There is some debate about the safety of tooth whitening for purely cosmetic purposes. If you are interested in reading more about this, the following journal article (written in dental-speak) discusses tooth whitening in great detail: Undesirable and adverse effects of tooth-whitening products: a review (Goldberg, Grootveld & Lynch, 2009)

What about veneers and cosmetic crowns?

“Veneers” (waver-thin pieces of porcelain which can be glued over the front of the teeth, for example if teeth are misshapen or severely discoloured not just on the surface) are quite often placed for purely cosmetic reasons, much like plastic surgery. Because they require the removal of tooth structure, they’re “unhealthier” than doing nothing (assuming it’s done purely for appearance’s sake) and the procedure carries some risk of doing damage to the tooth. They will also be need to replaced 10 or 20 years down the line. They are not reversible, so you’re stuck with them for the rest of your life. So you need to be very sure that this is what you want. As results vary considerably from one dentist to another, make sure to have a look at photos of previous veneers  they have done. You’ll notice enormous differences in what dentists think looks aesthetically pleasing – for example, some cosmetic dentists seem rather keen on making their patients look like horses, with rows of identically-sized and coloured chiclets. The last thing you want to do is spend huge money on a result that you’re not happy with and that is difficult to rectify. So do your research beforehand! Placing crowns for the purpose of improving appearance is even more invasive than veneers, as it requires the shaving off of even more tooth structure. Both veneers and crowns inflict trauma to the treated teeth and may then make root canal treatment necessary at a later stage. Also, some people have reported that they were not informed as to how much tooth structure would actually be removed and then were shocked and saddened when they found out. Always make sure that you understand what a cosmetic procedure involves before making a decision!

Conservative Cosmetic Dentistry vs. Traditional/Aggressive Cosmetic Dentistry

Rather than categorising procedures into “cosmetic” vs. “aesthetic” (which are not clearly defined anyway), a better way is to distinguish between 1. tooth friendly (minimally invasive / conservative) cosmetic dentistry and 2. traditional (aggressive) cosmetic dentistry. Tooth-friendly cosmetic dentistry generally does nothing irreversible to the teeth. This means treatments such as tooth whitening, resin bonding, or short-term orthodontics, where the results are to the greater extent reversible. Such treatment is unlikely to jeapordise one’s long-term dental health. Generally the aim is a big improvement but not true perfection. For some dentists, this approach celebrates our individuality, as this blog post from Fraser Hendrie, BDS illustrates:

“As part of the day [at a cosmetic dentistry seminar] I was reminded of a very powerful 60 second video by the manufacturers of the Dove range of soaps and cosmetics, that I first saw a few years ago. I think it is as powerful today as when it was released in 2005. Take a look and see what you think…..

It serves as a timely reminder that in the field of cosmetic dentistry, aesthetic dentistry or whatever you actually want to call the process of enhancing and improving a smile that we need to keep our aims grounded in reality. More importantly it reminds us that almost every cover shot that we see on glossy magazines has been digitally manipulated in some way so these highly altered images are not the best benchmark by which to judge any part of ourselves. Don’t get me wrong I think that enhancing any aspect of ones self or situation with which we are unhappy can be a positive and life affirming thing to do, be it eating healthily, a new hairstyle, drinking less alcohol, exercising more or indeed improving a smile. I simply believe that chasing a false image of perfection may not be the route to happiness. So if we want to improve our smile (which is really the only area where I feel qualified to comment) what can we learn from this? I can only speak for myself but, for me the answer is that the media’s portrayal of perfection can be an illusion and I think it highlights the importance of realising that any cosmetic treatment is done for ourselves and not for others.”

In contrast, “traditional” cosmetic dentistry can include porcelain veneers, crowns, bridges – or anything else that involves drilling away a significant volume of otherwise healthy tooth. These treatments carry with them a need to be re-done every so often and usually are also associated with an increased risk of the treated tooth requiring root treatment in future. The key factor here is once you have them, you are stuck with them for life.

If you are considering cosmetic dentistry…

If you’re considering appearance-improving dentistry, here are two questions to ask to help tell the difference between someone who is into tooth friendly dentistry vs a more traditional approach:

:?: If all other things were equal, would you prefer to improve an otherwise healthy smile with porcelain veneers, resin bonding or orthodontics? The conservative/tooth-friendly dentist will usually answer:

  • first preference: orthodontics
  • second preference: resin bonding
  • third preference:  porcelain veneers

(NB there are some very good reasons why occasionally this order is changed but they should be able to explain exactly why. E.g resin bonding does not hold up so well in the mouth of a heavy smoker for example.) :?: What do you consider to be a smile makeover? A conservative / minimally invasive  dentist will say: treating the least number of teeth to produce the result that you are happy with. A more aggressive dentist will talk about a minimum of 6 8 or even 10 units (teeth) of treatment to obtain an “ideal smile”.

Of course, a minimally invasive smile makeover may also produce a fake appearance, depending on both your own vision and the vision and skill of the dentist. But at least, this is not such a big issue if the treatment is largely reversible.

Further Reading:

“I Have Had Enough” by Gordon Christensen (PDF)