Excerpts: Is esthetic dentistry really a health service? Are we spending too much time emphasizing esthetics and helping patients look their best? Are we answering our patients' needs or our own needs when we speak of the advantages of cosmetic dentistry? This editorial will attempt to answer these and other questions about the value of esthetic dentistry in the overall scheme of health science. But first let us look at how dentists view patients.

When you look at a face, what do you see? Most dentists tend to see teeth, because they are trained to do so. However, others see a face and then determine from that visual image of the face whether the individual is friendly, intelligent, plus a number of other characteristics, based on physical appearance. The shape of the face, teeth, and lips and other physical characteristics influence our own physical and psychological reactions to another person. Most significantly, faces, and especially the smile, can also influence our decisions about what we buy. Magazine publishers will tell you that issues that show full faces, particularly those with smiles, sell more copies ofthose magazines than other issues. Some advertising authorities have called it "smile power".

In 1988, an editorial by John Gilbert questioned dentist motivation in esthetic dentistry. He said that an entire personality change could take place in a person who received information from a professional expert, the dentist, that a smile is not up to standard. Even in routine cases, the planting of a seed of doubt when relating esthetic information to a patient can have serious short- and long-term consequences. Then he said that the patient's desire not to have an esthetic analysis must be respected. I think that is valid. However, he also said that in many cases patients will show interest in maintaining health only if esthetic concerns are also addressed. Too many patients neglect their posterior teeth because they know that people see the anterior teeth, and they understand the value of improving or correcting what they believe is visible to others. Gilbert also quoted Brisman (1982), who pointed out that there are clear differences between what is esthetic to dentists and what is esthetic to the general public. So, has the dentist in this situation created a problem where none existed? ---

In order to address the issue of whether or not esthetic dentistry is a health service, dentists should ask themselves some specific questions: Should resources be spent on porcelain veneers for individuals with mild tetracycline staining or on the millions ofAmericans with limited access to dental care and a huge unmet need for basic treatment? ---

Webster defines esthetics as "beauty or the study ofbeauty; or, an awareness ofwhat is beautiful or artistic". Throughout history, the standards ofbeauty have changed. They also vary for different countries and even regions of countries. But a common denominator exists, and that is proportion. There are many areas of agreement between cultures on what is essential for physical beauty. Indeed, the principles of esthetics are universal and need to be understood if esthetic failure is to be avoided. However, there is a need for continued research to verify and expand these principles.

When we look at faces and analyze them, we can use a facial caliper developed by Ricketts (Goldstein, 1993) for measuring proportion. This allows teeth to be shaped and proportioned better, and then we can look at faces in a manner similar to that in which plastic surgeons look at the face. Dentists have the power to destroy a face or make it more beautiful. They can enhance the smile or ruin it. Perhaps more significantly, they have a dual responsibility: protecting what already exists, and not making it worse. Unfortunately, we see too many patients who have been ruined. There are too many malpractice cases occurring throughout the US, and perhaps in other parts ofthe world now, because of dentists who violated certain principles of esthetics. So just what are the consequences of this "situation"? Those patients who have sufficient funds can try another dentist to help reverse the failed esthetic treatment. However, those who cannot afford this added expense must suffer the consequences of living in a world in which emphasis on physical beauty leaves them at a decided disadvantage. In order to understand the extent of this disadvantage, I examined a considerable amount of research on the subject. I first asked questions: 'Is our society obsessed with beauty? Are we obsessed with beautiful people?" From the moment of birth, good-looking people often enjoy big advantages, while less attractive individuals are penalized by the subconscious or "hidden" responses they provoke. And there is proof. Research has shown that good-looking men and women win more prestigious and high-payingjobs (Goleman and Goleman, 1987). Criminologists find that good-looking people are penalized less. Beauty does rank as a top factor. In Psychology Today (Berscheid et al., 1973), 57,000 people tore out a fourpage survey, filled it out, put a stamp on it, addressed it, and sent it in. They "screened" out what they didn't like about themselves, or about their bodies. Above their shoulders, it wasn't the nose or the eyes: It was the teeth about which they were most concerned because they believed they couldn't do anything about them.

Jurors go easy on handsome rapists. In one study of students (Pecoraro, 1982), 82% of the students judged an unattractive "mock" suspect guilty compared with 57% who found an attractive suspect guilty of the identical "crime". The unattractive suspect received 14 years of "punishment" vs. 10 years for the more attractive suspect. So we do make judgments based on physical appearance.

Ed Joy, of the Medical College of Georgia, has applied to orthognathic surgery the research of Cavior and Howard (1973) on facial attractiveness to demonstrate how criminals may not, in some cases, have taken on anti-social behavior if they had looked better or if they had an improved self-image. Plain girls can have more cases of high blood pressure. The way we look can even affect us medically. Good-looking children are better students, athletes, and socializers than are ugly kids. Attractiveness or the lack of it affects us at all ages. Goleman and Goleman (1987) found that teachers go easier when disciplining attractive children. Good looks are powerful chips in the "dating and mating" game.

In still another study (United Press International, 1977), one which may be even closer to the profession of dentistry, researchers found that "homely" persons are likely to be hospitalized in mental institutions longer than other patients. The same two-year study also concluded that unattractive patients often did not receive the care they deserved, they were visited less often, and were judged to be less pleasant. Most amazingly, a study by Gilmour (1988) demonstrated the cruelty that can be associated with being unattractive. When a group of children is responsible for some minor incident of damage, and no one will admit to the act, whom do you suppose is typically blamed? Unfortunately, the overweight child with the crooked teeth, not the slender, adorable one. Children are most afraid of losing face, being thought of as unattractive, stupid, or dishonest, especially by their peers. These fears are based in the child's perception ofhow he or she should compare with peers on appearance, particularly on facial appearance. We want to look like, dress like, or identify with our peers.

Skeptics may say that we ingrained this into our children; we're too conscious of esthetics. However, studies (Langlois et al., 1987) show that, at birth, babies respond more positively to attractive faces than unattractive faces: The attractive face holds a baby's attention for a longer period of time. Right from birth, it seems to make a difference. Concepts of beauty seem to develop early and, right from birth, seem to make a difference (Findlay, 1987).

So, to be attractive means all of these adjectives: You are perceived to be interesting, kind, independent, good, strong, happy, sensitive, and poised. Attractive people are thought to be more successful and more sociable. We tend to think that most unattractive people have a poor self-image. However, many unattractive people have a healthy self-image. We expect attractive people to have a healthy selfimage. Yet too many people in our culture are attractive, even beautiful or handsome, and yet they have a poor self-image. So, in some cases, it may not matter how we look, provided we like the way we look and we project that feeling. That is what seems to be important. If patients are satisfied with the way they look, then shouldn't dentists be also? Is it necessary or even advisable to put them through an esthetic analysis? The answer is, only if they raise the possibility that they can be improved upon.

Changing a smile can change a life. Dentists should be satisfied when patients like the way they look. Because many dentists happen to be perfectionists, they tend not to be satisfied until their patients look the way they think they should.

Disliking your looks is not just a matter of vanity. Both men and women who perceive themselves as physically attractive can have poor self-esteem, difficulty in social situations, and increased vulnerability to the depression that unattractive people can have. The key to it is that poor body image (King, 1988) is one of the main elements in self-rejection. That's why dentists and their staffs should stop using the word "vanity" in their practices. Patients should benefit from whatever service they want or need and not bejudged by the way they look or are perceived by the very profession they came to for help. By providing for the patient's need or desire for a more attractive appearance, dentists also help to ensure them a better selfimage, which can lead to all the benefits associated with being or feeling attractive. Most significantly, dentists can help to erase the "hidden prejudices" and create the means for a happy and successful life for each patient. ---

Several years ago, I estimated that approximately half of patient funds spent on dentistry was related in some way to esthetic dentistry. Thus, in the United States alone, well over 15 billion dollars will be spent this year on items from orthodontics to replacing missing anterior teeth, improving tooth color, and even prophylaxis to help make teeth more attractive. I further estimated that over 7 billion dollars would be spent by individuals who are unhappy with the results of previous dental treatment. This could vary from discolored composite restorations that did not last as long as the patient expected, to anterior crowns that did not satisfy the patient's esthetic requirements.

While my estimate may be high by a billion dollars or so (some believe that it is low), the fact remains that huge sums of money are being spent annually by people around the world trying to satisfy their own need for an improved appearance. More money for dental research related to esthetic dentistry is just part of the problem. We also need to be cognizant ofthe need for additional focused education for dental students so that they graduate better prepared to solve their patients' esthetic problems.

Dental research and education can do a great deal to help save patients money and dentists much of the needless stress associated with esthetic failure. Perhaps the first step'-in realizing this increased need is to recognize that esthetic dentistry is a health service... .and an extremely valuable one at that.

>>> See: Is What Is Beautiful Always Good?