Patient Selection for Esthetic Dentistry

A basic focus is to be able to differentiate patients' "needs" from their "desires." Patients' needs refer to issues affecting their oral and potentially general health for which the responsibility falls to the dentist to point out the specifics regarding disease or abnormal development. Patients' desires refer to esthetic issues that do not affect general health for which the responsibility falls to the patient to convince the dentist to present treatment options. Obviously, most patients with desires will also desire to have their needs met, but for the purposes of patient communication in esthetics cases, differentiating between needs and desires allows clinicians to guide treatment discussions toward realistic goals and manage patient expectations.

Because an esthetic smile is central to a person's self-perception as well as to his or her confidence in social and work environments, it could be considered a cornerstone of the overall well-being of our patients. The resolution of esthetic issues can be both a desire of the patient as well as a need; it isn't necessarily either-or. However, where the issue falls on the spectrum between desire and need can be telling. Patients whose esthetic concerns fall almost entirely on the desires end of the spectrum often seek care using an entirely different thought process than those whose esthetic concerns fall largely on the needs end of the spectrum.

When engaging patients who are seeking esthetic treatment, to achieve a successful patient-provider interaction that ultimately results in patient satisfaction with the treatment rendered, a certain skill set must be developed. Specifically, clinicians need to learn how to screen in potential patients who will benefit from their care and screen out those who will not or cannot appreciate their care—the patients about whom clinicians say, "I regret the day that they entered my office." It is possible to achieve a clinically outstanding result and still have to deal with a disgruntled patient. These are patients who you do not want in your practice.

Although extensive studies and case reports exist in the literature that address the anatomy, materials, protocols, technology, etc of esthetic dentistry, the literature is limited regarding information on how clinicians should facilitate explicit engagement of these patients in order to fully realize and understand their expectations. Regardless, clinicians must be able to succinctly articulate their thought processes while engaging patients about esthetic expectations in order for mutual satisfaction with care to be realized.

Central to meeting the esthetic expectations of patients who desire to improve their appearances is expanding the perspective from the teeth to the face. Patients can have an outstanding result regarding the final appearance of the teeth but still perceive it as a failure if the teeth are not in harmony with the face. For example, the teeth may be too small or too large for the face. Or, other aspects of the face may be in disharmony with the teeth. For example, the upper or lower lip line or midline may be positioned such that the teeth are in disharmony. Moreover, one part of the face may be in disharmony with another part of the face, which can make even the most ideal dental outcome almost irrelevant.

So, what elements of the dentist-patient interaction are essential to reducing the chances of misreading the patient's motives and improving the chances of patient satisfaction with treatment? Master clinicians start with open-ended questions with the intent of earning the respect of the patient through honesty, compassion, patience, and competence, then they work to create the perception of value in what treatment can be provided. ^1-3

The first step involves gathering the basic information. Ask patients what brings them to your office so that you can hear their reasoning in their own words. Ask them about what they like and don't like about their smiles. To elicit even more meaningful information, follow up by asking them how they arrived at those decisions about their smiles. Asking what patients like about the smiles of people that they know or famous people can help you glean information about the general aspects of a smile that patients find desirable. For patients who are less specific or hesitant, asking what they would change if they were given a magic wand can get them talking. Remember, the discussion should be based on the entire face, not just the dental model, and it's a good idea to avoid using a hand mirror at this point. The conversation should be more about their overall goals for treatment. Tips for initial communications in esthetic cases include the following:

• Be a referee. Explain to patients that you just "call it as you see it" and make recommendations—the decisions are theirs to make. This helps empower them and establish mutual respect.

• Tell the truth. When discussing patient needs and desires, present all of the facts without withholding any details or options. This is essential to establishing trust.

• Stand your ground. Although it is important to offer multiple options to meet patients' needs when indicated, equally important is explaining that you won't deliver esthetic treatment in a manner that could otherwise negatively impact their oral health. As Robert G. Ritter, DMD, notes, "Just because they don't want to do the right thing doesn't mean that you have to do the wrong thing."

Patients who present with specific esthetic concerns, such as those regarding the color, spacing, or positioning of their teeth, and are interested in ideal treatment solutions as well as those who demonstrate that they are listening to your recommendations, such as that their teeth are too large or too small for their face, should be considered favorable to accept for treatment. Alternatively, there are many red flags that can indicate that a patient may be unfavorable to accept for esthetic treatment, including the following:

• The patient wants a quick fix (eg, refuses orthodontics)

• The patient believes a pleasing esthetic result is deliverable without multidisciplinary intervention (eg, refuses periodontal treatment).

• The patient wants unnatural veneers that look like Chicklets.

• The patient takes a mirror and points to one spot.

• The patient wants something that cannot technically be done.

• The patient continually wants to change the mock-up.

• The patient wants his or her teeth to look both white and natural.

• The patient is solely motivated by price even if he or she can afford ideal treatment or is exclusively dealing with insurance.

• The patient tells you what you should do.

• The patient wants all of the central and lateral incisors at the same level.

• The patient presents with severe wear on his or her natural teeth.

• The patent makes the dentist feel bad or sorry for him or her (bad things can happen)

Patients who are overly analytical or picky can be a problem more often than not and should be considered unfavorable. These are patents who do not know what they don't like about their smiles or who express obscure expectations. Overly analytical patients often reach for a mirror or are highly critical of the mock-up. These are indicators of patients for whom you may be unable to provide a satisfactory outcome.

Another type of patient is one who presents with feelings about his or her smile and makes decisions based on emotions. These patients are usually favorable to accept. Although emotional patients know what they don't like about their smiles, they are open to solutions. However, treatment may take longer to discuss, and some esthetic concepts may require additional explanation.

In situations involving overly analytical patients, clinicians can often use effective communication to convert them into emotional patients who have more defined and reasonable expectations that can be successfully met with appropriate treatment. Unfortunately, some patients never come around. Respectfully explain that you don't believe that you can meet their expectations and recommend that they seek another opinion. If you are honest, compassionate, and ethical during your esthetic consultations, any patients you are forced to reject who later become favorable will return to you for their treatment because you developed their trust.

Esthetic dentistry can be more of a desire than a need; therefore, clinicians need to develop the skill set to engage interested patients, assess their expectations, and determine their likelihood of being satisfied with the results of treatment in order to ascertain whether or not they are appropriate to accept. Not all patients who present for esthetic care can or will be satisfied with the best technical result; however, this skill set and patience on the part of the clinician can lead to the better selection of patients who will truly appreciate the care and experience the joy of an improved esthetic persona. When clinicians learn to identify the patients who will be able to find a satisfying esthetic result from among those who will not, and they make this identification before beginning treatment, esthetic dentistry can be a fulfilling and enjoyable part of the general practice.

David C. Johnsen, DDS, MS, is a professor in the Department of Pediatric Dentistry at the University of Iowa College of Dentistry in Iowa City, Iowa.

Robert C. Margeas, DDS, is an adjunct professor in the Department of Operative Dentistry at the University of Iowa College of Dentistry in Iowa City, Iowa. He maintains a private practice in Des Moines, Iowa.

Marcos A. Vargas, BDS, DDS, MS, is a professor in the Department of Family Dentistry at the University of Iowa College of Dentistry in Iowa City, Iowa.