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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
From ensuring precise composite color matching to offering in-office teeth whitening, cosmetic dentistry can take your practice to the next level.
Patients judge their dental work by a different set of standards than dentists. Clinicians, obviously, have a laundry list of items by which a restoration can be evaluated, including function, esthetics, fit and countless other elements. Patients, on the other hand, are chiefly concerned how a restoration looks.
“They can’t really judge the margins” says Dr. Betsy Bakeman, DDS, FAACD, a cosmetic dentist in Grand Rapids, Michigan. “They can’t really judge how well it fits. They pick up the mirror and they look at it. One of the best things they can say is, ‘Which tooth was it?’”
To that end, cosmetic dentistry is important to every practice. Cosmetic dentistry can include simple things like taking the extra effort to ensure a precise composite color match, or it can be as involved as a full set of maxillary anterior veneers.
“All dentistry is cosmetic,” says Dr. Jason Watts, DMD, a general dentist in Lithia, Florida. “The only dentistry that is of necessity is an extraction. So, anything we do for a patient, whether it’s a Class V filling or whether it’s a chipped tooth, it’s all cosmetic. So, whether they want to admit they’re doing cosmetic dentistry or not, they really are.”
No matter how involved the restoration may be, cosmetic dentistry matters to the doctor as well as the patient.
What is the benefit of providing cosmetic services? Is it financial? Professional growth? Service to the patients?
“It’s all of the above,” says Dr. Tanya DeSanto, DDS, a cosmetic dentist in Springfield, Illinois, and board member of the American Academy of Cosmetic Dentistry. “The driving force is the passion and the energy that you experience by changing someone’s life. People may find it a little bit corny, but it’s very, very life changing. If you change someone’s smile, you’ve changed a life. When you finish a case, people cry. They just can’t believe it. People move on, they get better jobs, they get married, they lose weight, they reinvent themselves. To know that you were the seed behind that, it just doesn’t get any better than that.
“And everything else comes from that,” she continues. “The financial growth, the personal growth, all of it just happens, all together.”
“Definitely service to patients,” Dr. Bakeman adds. “That’s huge. It brings a lot of joy to the practice because you make people very happy. It’s a very positive thing; a lot of positive energy is created by providing cosmetic dentistry. Everybody’s happy - the patients are happy, the staff is happy. Doing that kind of work is very joyful.”
The clinician also gains a sense of personal satisfaction from being such a force of positive change.
“It’s really personally satisfying, for me, to know that I’ve given somebody the best service possible and to realize an immediate gratification after seeing a job well done,” says Dr. W. John Rowe, Jr., DDS, AACD, a general and cosmetic dentist in Jonesboro, Arkansas. “Of course, it’s financially gratifying, too. That’s natural for any successful business transaction. It’s mutually beneficial for both sides.
“But, most importantly, it’s cohesive with my practice vision. It’s an exceptional feeling to make a difference in somebody’s life, to make an impact, and to help them achieve their desires. People tend to make snap judgments about each other. Appearance matters, and an attractive smile often contributes to success in social settings. Most people put a really large value on their appearance, so it’s exciting to be able to help people put their best foot forward.”
While there are altruistic gains, there are, of course, financial benefits too.
“Elective dentistry often operates with different financial arrangements,” Dr. Bakeman observes. “Often, patients owe money for those services. It’s often done fee-for-service and it’s billed at the time of service. Patients are expected to pay at the time of service, so cash flow can be positive.”
Dr. DeSanto observes that business naturally increases when doctors offer cosmetic dentistry.
“The number of patients noticeably increases,” Dr. DeSanto says. “Because when people are happy with their smile, they tell everyone about you. It’s not only helping someone smile, but it’s your best marketing tool. Our practice has grown exclusively on referrals.”
While there are plenty of upsides to offering cosmetic dentistry services, it also requires plenty of effort and attention to detail.
“It can also be challenging,” Dr. Bakeman explains. “You have to be a bit of a perfectionist. You have to be willing to critique your own work and be willing to send things back to the lab if you’re not completely satisfied, and you have to be your own biggest critic and be comfortable with that. The most important thing is that the result be the best it can be when you finish. Exceeding patients’ expectations is always the goal.”
Up next: How to keep up with changes in the industry
Keeping up with the times
Times are changing, especially for the dental field. New materials and techniques are introduced so regularly that it is incumbent on doctors to keep up with innovations. Further, many doctors may find that what they were prepared for in dental school is not sufficient to meet their patients’ esthetic demands.
“Dentistry, in the past - even 30 years ago when I was in dental school - was basically about function,” Dr. DeSanto says. “It was always about function. The focus was never on cosmetic dentistry but more on form and function. Today we need both, equally, for a successful case completion. Dentistry has evolved as a profession. It’s an art and science, combined. It’s not the same field that it used to be. When I was in school, it was silver fillings, gold onlays - I haven’t done those procedures in 25 years.”
Dr. Rowe credits the American Academy of Cosmetic Dentistry for giving him the knowledge he needed to offer the best cosmetic services.
“I tell people, ‘In dental school, I learned not to be dangerous,’” he laughs. “I learned to be a sound, competent practitioner, but cosmetic expertise, excellence, I gained a lot of that knowledge through postgraduate study and the AACD’s credentialing program. As a learning experience, accreditation has been a huge asset to me by sharpening both my eye and my skills to be able to offer exceptional, high quality esthetic dentistry. AACD accreditation teaches toward the concept of responsible esthetics. That functional dentistry not only looks good but is well-planned to provide for a lifetime of service. Oftentimes, dentistry is expensive, but it should be an investment that people believe in when it’s executed properly.”
While dental school may not have been sufficient to teach cosmetic dentistry, there is a professional resource that doctors can turn to.
“So, where do you learn all this?” Dr. DeSanto asks. “I learned none of this in dental school. Basically, everything I learned was from the American Academy of Cosmetic Dentistry, years ago. I dove into their courses and I learned more in those courses year after year than I ever learned in dental school. I just kept seeking it out and I never miss the Scientific Session every year. I read the journals and just really dive in.”
“The American Academy of Cosmetic Dentistry is bar none,” Dr. Bakeman adds. “They have a really high-energy meeting, they have many of the top clinicians - national and international - so you’re exposed to a lot of different educators. The Annual Session of the AACD has dozens of hands-on workshops presenting an opportunity to try lots of different materials and techniques, and as dentists we are very hands-on. We like to get in there and try it. And if you find an educator with whom you connect and you want to learn more from this person, many educators have more in-depth courses you can pursue. The AACD Annual Session provides a broad-spectrum exposure to the world of cosmetic dentistry.”
In addition to education, the AACD offers an accreditation program that allows doctors to demonstrate their training and skill. Accreditation requires training, testing and the evaluation of five different case types.
“These case types involve five different kinds of cosmetic dentistry that any dentist stating proficiency in cosmetic dentistry should be able to perform to the accreditation standard,” Dr. Bakeman explains. “It’s one thing to go to a course and listen to the person and say, ‘Okay, yeah, great, I learned a pearl or two and I’m going to go back and use it in my practice.’ But it’s another thing when you know you have to actually document your work and pass the test. There’s something about the need to deliver that makes the focus on the learning and implementation more focused, intense and effective. People who go through that accreditation process say, ‘It was a lot of work, but I became a better dentist.’
“You may be good in one area, like porcelain veneers, but you may not have been as proficient with direct composites,” she continues. “You may have been good with direct composites, but you may not have been able to replace a missing tooth in the front of the mouth, manage the tissue architecture and produce a result that blends seamlessly with the adjacent dentition. The accreditation process forces an individual to excel in all areas of cosmetic dentistry.”
For those who want to start small and improve the cosmetics services that they offer, Dr. Watts says that the education can be freely and easily acquired.
“Dental students care more about how composites and fillings look more so than older dentists because they’re coming out of school and they want to prove themselves,” Dr. Watts observes. “But cosmetics start to matter most with the smaller differences, not the bigger changes. Everything is about smaller differences that achieve an overall, more pleasant result, and it takes time to learn those differences. They just have to go out there and find the proper courses. Most of them are free online. You can find all CE free online today or YouTube videos that will help you.”
Up next: Adding cosmetic dentistry to your practice
An easy add
Adding cosmetic services to one’s practice is neither daunting nor expensive. The best way to begin, Dr. DeSanto says, is by starting small.
“One small step takes you light-years with people,” she says. “When you get the person who comes in for their six-month checkup, maybe they have a small little chip on their tooth, or one tooth out of position a tiny bit. You can start by smoothing the chip they’ve lived with for 20 years and balance their centrals a little better. You’ve created a little more symmetry in their smile that took 30 seconds of your time. You just won that person over forever, and you can do things very small and simple to start - Invisalign, ClearCorrect and the clear aligners, that kind of dentistry is very simple. Making trays to line up somebody’s front teeth a little bit better, it’s very affordable. It’s not something like full-mouth, bracketed orthodontics. And it’s fast. You can move a tooth with slight alterations of position in just several weeks. Small steps make a big difference.”
Whitening services have become very popular with clinicians and is another straightforward service to offer.
“Whitening is a huge thing to offer someone,” Dr. DeSanto says. “Offering an effective whitening system in-office, if someone can walk in your office, and walk out later and their teeth are six shades lighter, oh my goodness. You’ve just boosted someone’s confidence 10 levels. It’s so fun and rewarding because it’s instant gratification, and that’s what today’s economy and today’s population mandates. Everybody wants something now, and that’s definitely something you can do now that just makes a big change in someone’s life and confidence and self-esteem.”
Advancements in materials have made esthetics better and easier for clinicians.
“When you’re talking about composites, for example, choosing the right composite system based on its physical properties and having mastery over the components of any particular system are equally important to making you successful, esthetically,” Dr. Rowe explains. “If you match the materials with the appropriate case, sound planning and well-honed skills, I really think you can be successful and not have to invest in every single system available.”
Once the clinician gets started, offering premium services can be well received by patients.
“Ultimately, there is a huge difference made by choosing the right laboratory partner. Working together with a master ceramist, having the support of a great ceramic artist (often an AACD-accredited ceramist), is key for any cosmetic practice,” Dr. Rowe says. “That can sometimes be expensive, but if you build value with the patients and offer the patients a choice so that they do know the difference in what they’re getting and what possibilities there are for their teeth, most times the patients will surprise you and they’ll opt to pay a little more to get the smile that they want.”
And while some specific services require a relationship with the vendor (like name-brand clear aligners, for instance) those services can still be offered using just a skilled lab.
“You don’t need any special contracts,” Dr. DeSanto says. “You need to find an in-office whitening system that you like, that you researched, that works well for your office, and something that isn’t causing sensitivity and is easy and affordable. Choose a lab that you want to have a relationship with that can make clear aligners for you – most any lab can make that for you. You can talk to the lab that you’re working with for crowns and bridges and dentures and ask if they’re doing clear aligner treatment and send them your first case.”
Dr. Rowe shares a similar viewpoint.
“It’s not absolutely necessary,” he says. “There are some vendors that have patented certain processes and have also invested a significant amount of time and effort into marketing, and you can benefit from partnering with them. But there are other ways of doing things like clear aligners where you can work with a skilled orthodontic laboratory that can provide a similar service. There are benefits in different processes that certain companies offer that would be beneficial in becoming involved with them, but many times alternative services can be performed with a great laboratory, or even if you were inclined to do the lab work yourself.”
A partnership with laboratories that share the same vision of esthetics is an important part of the process.
“These highly skilled technicians that provide highly esthetic results are in strong demand and can be scheduled out for months. When scheduling a patient for this type of treatment, we schedule with the patient and we also reserve time with the laboratory, so we have a reasonable turnaround time. If that isn’t done, there could be a wait of several months before the restorations are returned. There is different planning with the laboratories and also regarding financial arrangements with this type of dentistry.”
Once the clinician dips his or her toe into the waters of cosmetic dentistry, he or she can grow from there.
“You can dabble in small amounts of cosmetic dentistry, then you get the excitement and you kind of get addicted and you further your training by going to a conference about cosmetic dentistry and picking your subject matter and just advancing your skill set a little more,” Dr. DeSanto says. “It’s so fun, it’s so rewarding, because you just see these patients and their lives just turn around in front of your eyes. They’re excited and they’re happy. It’s your best marketing because they’re going to refer everybody to you. You’re creating your own internal marketing.”
Up next: How to get started
It’s easy enough to offer cosmetic services. Dr. Watts explains that one does not even have to promote himself or herself as a cosmetic dentist - just reach out to patients.
“Cosmetic dentistry starts by asking the right question,” Dr. Watts says. “Every dentist has the materials in their office to do cosmetic dentistry, they just might need a better lab. It really just starts with asking the proper question of, ‘What don’t you like about your smile?’ That simple question will open the door to cosmetic dentistry. You don’t need to advertise that you are a cosmetic dentist unless you’re doing it routinely, but you just find those patients who may not be happy with themselves because of their smiles, so they don’t smile. And those are the best candidates for cosmetic dentistry. If you have a bur and a handpiece in your office and you can cut a crown, you can do cosmetic dentistry.”
And each patient is unique in his or her cosmetic dentistry needs.
“Every mouth is unique in what it needs to be treated with,” Dr. Watts explains. “Sometimes cosmetic dentistry for a patient may be putting veneers on to eliminate staining because the patient is older and their teeth are just drying out and they’re just more yellow. Sometimes cosmetic dentistry could just be covering up cervical lesions on a patient and doing nice composite work. There’s no reason why any dentist shouldn’t say they won’t do cosmetic dentistry, because all dentistry is cosmetic.”
Dr. Watts agrees that asking patients a simple question can get the process rolling.
“Just say, ‘Hi, are you satisfied with your smile? No? What don’t you like about it?” Dr. Watts says. “And then you hand them a mirror and they start pointing everything out. They tell you this tooth is crooked, that tooth is crooked. Or they tell you they used to have braces on and their teeth just started getting crowded again. Or you say, ‘Tell me a story about how your teeth got the way that they are.’ And they may say, ‘Well, when I was a kid, I got hit by a hockey puck in the face.’ Or maybe, ‘I was addicted to drugs’ or ‘I love coffee and orange juice’ and that destroyed their teeth. Everyone has a story; you just have to be willing to listen. Once you listen, you’ll be surprised about what other treatments you can get.”
For clinicians considering expanding their cosmetic services, there is some helpful advice available. Education is always a great place to start.
“If you have the hunger and drive to do it, get the training to learn how,” Dr. DeSanto advises. “There are so many different kinds of bonding agents and kinds of porcelains and materials. It’s really gaining knowledge of the materials and knowing all the eggs in your basket. Get it all sorted through, what might work best for each patient situation.”
Dr. Bakeman recommends adding digital photography to your practice. For those who may not be comfortable with digital photography, she says the obstacle is not difficult to clear.
“It seems like a big hurdle, but there are courses,” Dr. Bakeman says. “Mastering the camera is really important from the get-go. Photographic documentation is used in diagnosis and treatment planning, laboratory communication, and communicating competency to other patients who have similar problems and who could benefit from comparable solutions. Well-done images also provide a learning tool for us to improve. We are able to critique our outcomes and determine where things went well and where there is room for improvement.”
Finding a mentor can also maximize your success when it comes to diving into cosmetic dentistry.
“It’s easier to do it by finding a mentor and developing a relationship with somebody who’s already done it,” Dr. Rowe says. “And that’s what’s going through the AACD in the accreditation process. One of the real benefits it offers is to help you get in touch with others who share that same interest, that same passion, and developing those relationships. There’s no reason to reinvent the wheel when other amazing clinicians who have already done it are out there and are willing to help you, just because they want to see the best thing for the profession.”
“A good mentor can guide you,” Dr. Bakeman adds. “I have numerous people email me and say, ‘I’m interested in doing more cosmetic dentistry, getting better at this. Where do I start?’”
“It is important to know where each person has been,” Dr. Bakeman continues. “‘What is your educational background? What have you done so far?’ Then, depending on where they are, I send them on their way to take a photography course or learn about occlusion, attend hands-on workshops at the American Academy of Cosmetic Dentistry. It is a continuum of learning and a process and it is not going to happen overnight. It’s really exciting to see people grow and improve. The people I mentor send me images of the dentistry they are providing. Requesting feedback is an important element in improving - humbling, but important. To see the dentistry improve over time is really exciting because you know it has an incredible ripple effect. The dentist’s confidence and skill level increases at the same time the dentist and their team are providing better dentistry, so much more eloquent and refined. The patients are the ultimate beneficiaries.”
Function is, of course, important to dentistry. However, cosmetics matter, and, to some degree, every dentist is a cosmetic dentist.
“You may not believe that you do cosmetic dentistry,” Dr. Watts says. “But as a dentist, you are a cosmetic individual helping patients achieve a healthier, better mouth and better smile, and that’s what cosmetics is.”