February

We are in the month of love and romance valentines and …learning how to walk the thin line for ethical provision of the ultimate level of dental beauty.

On day 5 we teach delegates how to provide patients with ceramic veneers. The day starts with a discussion on the ethics of this type of treatment. We tackle that first as it’s another infinite subject and one we will explore in this blog. Most of the day is then spent on a step by step, problem by problem, error spotting by error spotting lecture and hands on day.

Again, our goal is to put delegates in a position so that when they leave the lab there is the smallest possible capability gap between the lab environment and their practice. We know the first case they do will be the steepest learning curve so we, in no uncertain terms, tell them to find one and get going. After all, who doesn’t want gorgeous teeth right?? If they can practice what they have learned within a few weeks of completing this day, the momentum and their skills get the best chance of permanently expanding their comfort zone and offering up this new treatment option. Everybody wants nice teeth don’t they? Just offer a million dollar smile to any random someone and get on with it!

Oh!  Oh no! That sounds like thin ethical ice. That sounds a bit dodgy mate.

The reason we emphasise ethics on day 5 is because we aren’t curing a disease. We aren’t repairing an injury or removing an inflamed pulp. We aren’t draining pus. We aren’t fixing an emergency or relieving pain…not relieving pain…are you sure?

There are different types of pain and I put to you that dentists, unfamiliar with even the fundamentals of psychology have man with a hammer syndrome. Pain, for them is organic. It’s inflammation and trauma and infection.

There are other pains and they are arguably worse. I’d contest that, in some circumstances we do relieve pain with aesthetics and that is an EXTREMELY fine line to walk. One which I try to walk everyday but feel wobbly, unsure of foot and always looking for input from my peers.

I’m not making the case at all that there aren’t people seeking aesthetic treatment who want to enhance their sexual market value. They may already rank very highly within this hierarchy they chose but want to be the Queen or King. Most patients seeking aesthetic care are perfectly healthy but just want to look better.

Looking good comes with vast advantages and power. Even people who label this axiom as a ‘sin’ and call it vanity look in the mirror as much as you do. They apply their creams, pluck their hairs, sculpt their locks, flex their muscles, choose their clothes and prefer good lighting. You can read Survival of the Prettiest by Nancy Etcoff or Beauty Pays by Daniel Hammermesh if you want to go deeper into this subject or want to see the incredible power of appearance. Some of the studies on what men will do for beautiful women are extraordinary and nothing short of life threatening.

Helen of Troy was the face that launched a thousand ships and the Apple of Discord leading Paris to choose love over all started arguably one of the greatest stories of all time. (The Iliad …obvs!!).

We have a thin ethical line to walk because provision of veneers often comes at a cost and that is natural tooth tissue.

When is it ethical to carry out this care?

My body, my choice right? So if a patient understands the risks they can get pregnant, tattooed, pierced, can shrink or grow their muscles, UV expose themselves to the melanoma clinic, eat themselves obese to the point of death, exercise themselves infertile, own a list of twenty prescription drugs for preventable diseases and you are wetting your pants because I may take away 0.25mm of enamel.

Well let’s argue the other way. This is a Martin Kelleher’s Daughter Test adaptation example. His idea of The Daughter Test, to me is a masterpiece.

As you read the next sentence imagine the very act of reading it to the end meant you magically lose 0.5mm of enamel from your upper 4 to 4, would you make it to the end?

Goodbye lovely enamel, you did nothing wrong but I can’t stop reading, it’s like Richard is siren bewitching me with his words and on zero it’s literally the Pearly Gates for you, 3, 2, 1,…0!

Now think on this. Perhaps you didn’t finish that sentence or at least you wouldn’t have done if it really did cost that enamel. How much money would I have to pay you to read it?

Now Elon (first name terms him and me) is funding this so let’s say I offer you £10K. I’d guess you’d refuse. What about £750 million, I’d guess you’d try and read it twice.

So, the value of your enamel is somewhere between £10,000 and £750 000 000 and that is why this is an ethical question.

Sometimes the path is easier to walk. A patient clearly empty of any internal character and who has placed the entirety of their worth on their appearance can be spotted easily enough. The false belief that they will become of more value by damaging their teeth for veneers is a lie and although simpler methods for helping them may be possible, I won’t damage them for a lie. Perhaps I’m harsh in that but most of such patients present with lovely smiles already and are asking for something attention grabbing, TOWIE-esque, and I just cannot do it.

Patients with a form of psychosis, dysmorphic or with a personality disorder need careful discussion and consideration. We would recommend they are never managed alone. Refer them to an MDT of sorts!

Someone, reasonable, sane, reflective and capable of consenting, someone like you who just wants to look better. They aren’t asking for you to be complicit in sin. They are asking for what we all want, to look good and the benefits may…MAY…outweigh the costs.

With good techniques you often need to do almost no prep to the teeth and depending on lip tightness, soft tissue type and tooth angulation that is not at all uncommon. So those costs are really very small indeed. They then have the costs of maintenance and that shouldn’t ever be overlooked.

There is a landmark study below which has become relevant now.

Edelhoff D, Sorensen JA. Tooth structure removal associated with various preparation designs for anterior teeth. J Prosthet Dent. 2002 May;87(5):503-9.

Ceramic veneers and resin-bonded prosthesis retainers were the least invasive preparation designs, removing approximately 3% to 30% of the coronal tooth structure by weight. Approximately 63% to 72% of the coronal tooth structure was removed when teeth were prepared for all-ceramic and metal-ceramic crowns.

Up to 30% of the tooth removed (by weight) to fit them with a veneer. Come on.

Seriously who would do that to another person? Someone who needs help with their ethical compass that’s who.

Wow. The message here is that harm comes in degrees and there is no set and agreed amount of acceptable harm, that comes with some commensurate benefit that we can say is the clear border between right and wrong.

Someone ashamed of their smile and socially inhibited can go on to lead a richer fuller life without those encumbrances. To remove a few prisms of enamel and fit 8 veneers to make that happen, feels ok to me.

Someone desperate to get onto Love Island so they can swap STDs on TV with a bunch of petri-dish strangers and is willing to have 30% of their top ten teeth removed to win their first class ticket to get onboard The Syphilis Express….well that feels ethically wrong.

But where is the limit? For that we need to explore ethics and that takes up back to square one.

The pain relief we talked about earlier hasn’t really been qualified or quantified but I have come to know it is real. Be it a disfiguring injury, disease or just the natural cards you were dealt, feeling of shame about your smile and the perception of negative social judgment is real and painful.

For goodness sake, if someone is class 3 enough they get scored by the Ortho lot on their Index of Orthodontic Need and they carry out a decade of ortho and bimaxillary surgery. What disease did they cure? What infection did they remove?

None that’s what. They have built a socially and ethically sanctioned aesthetics machine that glues on metal brackets and breaks both your jaws. Good for them!

The pain of aesthetics or their lack, is psychological pain, its real and it hurts. But we label its cure under the banner of a sin.

Adding beauty to the world makes the world more beautiful. Doing it ethically is the fine line we walk.

What is ethics?

At its simplest, ethics is a system of moral principles. They affect how people make decisions and lead their lives. Ethics is concerned with what is good for individuals and society and is also sometimes discussed as moral philosophy. Doctors and dentists are required to act ethically in both their personal and professional lives.

If I ask you to do an ethical act right now I bet you don’t move. What is an ethical thing to do? An ethical action?  It’s hard to know if something ethical. It is easy however to point out unethical behaviours and moral wrongs.

Dentists in the UK have all been unwillingly recruited into a purity spiral where we all sit around scrutinising each other from a point of moral indignation waiting to look for the slightest impure thought or deed in each other. Then we can pounce and report and condemn and look down disdainfully at the filthy sinner, all the while polishing our own halo and whiter than white tunics.

I wonder if those that sit in the highest echelons of judgement are as seraphically pure as they would have us all pretend to be. Good God look at our MPs – both sides of the house…lol.

Ethics is a term is derived from the Greek word ethos which can mean custom, habit, character or disposition. The Greek Gods themselves were perhaps the most unethical group you could encounter.

Ethics covers dilemmas like, how to live a good life, our rights and responsibilities, the language of right and wrong, moral decisions – what is good and bad?

Most of our concepts of ethics have been derived from religions, philosophies and cultures. They infuse debates on topics like abortion, human rights and professional conduct and that latter one pertains to us.

If ethical theories are to be useful in day to day dental practice, they need to affect the way human beings behave. They need to provide answers.

Some philosophers think that ethics does do this. They argue that if a person realises that it would be morally good to do something then it would be irrational for that person not to do it. Hence our requirement to always act in the patient’s best interest.

But human beings often behave irrationally – they follow their ‘gut instinct’ even when their head suggests a different course of action.

Many dentists want there to be a single right answer to ethical questions when walking the line with treatment decisions. They find moral ambiguity hard to live with because they genuinely want to do the ‘right’ thing, and even if they can’t work out what that right thing is, they like the idea that ‘somewhere’ there is one right answer.

But often there isn’t one right answer – there may be several right answers, or just some least worst answers – and the individual must choose between them. That choice is the whole point of this article and for us it can be a source of discomfort. Moral ambiguity is painful because it forces us to take responsibility for our own choices and actions, rather than falling back on convenient rules and customs. We have to decide to walk a path and be prepared to explain our heartfelt reasoning.

At the very heart of ethics is a concern about something or someone other than ourselves and our own desires and self-interest. That is an attractive characteristic in a healthcare worker. To care about others. It may not get you your own ski chalet, Lamborghini or Daytona but it’s of value to me if I ever need you.

There are many forms of ethics one can consider. Are ethics pre-existing and we encounter them or do we as humans develop and create them? That reduces them to a set of opinions adjusted for today’s Overton window. I believe we, for the most part evolve our understanding of right and wrong. Sure, this gets hijacked by those wanting to label people who think differently to them as a sin, but for the most part we seem to be finding more sense as we understand human nature ever more.

The labellers, by the way, probably often don’t mean what they say, they just like to feel important and virtuous as part of a moral crusade. That’s a story for another day.

Back to work, walk the line, do what’s right, be prepared to explain your reasoning and if unsure ask for help. That’s what we built this all for.