Cosmetic dentistry procedures require consumer savvy

For 10 years, George Labbad of West Palm Beach avoided dentists. “I had this thing against dentists," he says. “They inject you, they drill, they fill, then on to the next patient.” Then a friend recommended highly rated cosmetic dentist Karen Glerum of Boynton Beach, Fla. After two years with Glerum and between $12,000 and $15,000 in procedures that included porcelain crowns, whitening, tooth-colored fillings and Invisalign braces, Labbad, 54, is all smiles.

“I can laugh and open my mouth and all you see is white,” he says. “The experience has totally enlightened me about dentistry.”

Almost 32 percent of Angie’s List members polled say they’ve had cosmetic dentistry, with crowns being the most popular procedure, followed by whitening, veneers and braces. While some say they get cosmetic work for healthier teeth or to feel more confident, 50 percent say they did it to improve their appearance.

Member Carl Vonderau of San Diego sees highly rated Dr. Lawrence Addleson for all his dental needs, from porcelain inlays to regular cleaning, and puts it simply: “It’s nice to have teeth that look good.”

The cosmetic dentistry category is the fastest-growing in the dental industry, according to the American Academy of Cosmetic Dentistry, with 200 percent growth in procedures since 1996 and 300 percent growth in teeth whitening alone. But the line between the profession of who can offer general and cosmetic dentistry is ill-defined and in many cases, nonexistent. The American Dental Association doesn’t recognize it as a specialty and any general dentist can market himself or herself as a cosmetic specialist.

Although about 93 percent of cosmetic dentistry reports on Angie’s List bear a grade of B or better, experts agree consumers must find a dentist they can trust. Addleson compares it to hiring a plumber or house painter — you get what you pay for, except the stakes are much higher. Bad cosmetic dentistry will at best leave you with an ugly smile, he says. At worst, it can devastate your oral health.

Few regulations for specialization

Who can do cosmetic dentistry or even what it is remains largely up to the interpretation of each dentist. Procedures the ADA considers potentially cosmetic —braces, porcelain crowns, veneers, bridges and bonding — can be legally performed by a general dentist but also overlap into the specialties of orthodontics and prosthodontics.

“Cosmetic dentistry can range from low-level whitening — I’m talking Crest White Strips — to full-mouth reconstruction,” says highly rated Dr. Michael Moats, a cosmetic dentist in Buffalo Grove, Ill.

As a result, the consumer is often confused about whom they should see for cosmetic work, says highly rated prosthodontist Dr. Keith Progebin of Washington, D.C. “Just because [a dentist] can do something doesn’t mean he or she should do it or is capable of doing it to the same standard of care as the specialist.”

Prosthodontics is the only specialty recognized by the ADA for cosmetic procedures. It requires a three-year accredited fellowship in all aspects of cosmetic dentistry, implants, dentures, full-mouth reconstructionand other complex issues.

Not that Progebin wants patients lining up at his door for only teeth whitening, basic inlays and veneers. In the absence of regulation, he says patients must be proactive in evaluating the work they need, asking good questions of their general dentist and seeking a second opinion of a specialist, if necessary.

Consumer caution necessary

Georgia McNulty-Hook of Redwood City, Calif., outside of San Francisco says she knows all too well the high cost of bad dentistry. “I wanted my teeth to look like a movie star’s,” she says, and adds that she went to Dr. Glenn G. Lew based on his glossy advertisements and plush offices.

“I’m 64. Old people get old-looking teeth — yellow. When Dr. Lew told me, ‘I’m going to crown every tooth,’ I thought, ‘Why not?’ He said it would be beautiful.”

The process took two years, required more than 15 crowns and cost more than $20,000. In fall 2010, one of her front crowns fell out. She paid Lew, who has a negative grade on Angie’s List, about $1,500 out of pocket before stopping payments on her 20 percent share of the insurance cost.

She says she’s been told by another dentist the remaining crowns will fall out eventually because her gums can’t support them.

Lew declined to comment on her case, citing federal privacy laws, but says his track record speaks for itself. “I have many, many happy patients from a career that spans 33 years now,” he says. “On occasion, as in any profession, difficulties arise with cases. I deal with these on an individual basis and always stand by my work.”

Addleson, not commenting specifically on McNulty-Hook’s situation, says bad cosmetic dentistry is fairly common and estimates about 25 percent of his practice is doing over other dentists’ shoddy dental work. Progebin estimates his redo’s on bad work from other providers is closer to 50 percent.

Patients should expect quality cosmetic dentists to offer an abundance of before-and-after photos. “If a dentist can’t show you his work, it probably means he hasn’t done any or it looks like crap,” Addleson says. Also, make sure the photos are of that dentist’s work, he adds, pointing out that some dentists buy before-and after photos to misrepresent their skill.

“Ask to talk to the patients in the photos,” he says. “Every photo on the wall, I not only did the work, they are only my patients.”

While all dentists can do cosmetic dentistry, Addleson, who’s past president of the American Academy of Cosmetic
Dentistry, says skill levels vary. The AACD, with 7,000 members worldwide, is the largest cosmetic dentistry association and offers six levels of membership, from general members with no requirements up to accredited fellows, like Addleson, who must pass oral and written exams and submit 50 examples of work for peer review.

Health first

Regardless of a dentist’s background, aesthetics always should take a backseat to oral health. That means a full oral exam that includes X-rays, gum exam and cleaning. Dentists shouldn’t start the aesthetics until they’ve addressed the other issues.

“Just because we do cosmetic dentistry doesn’t mean we can ignore that for which we are trained,” Addleson says. “Especially gum disease. If you have gum disease in the front of the mouth and then you do veneers, that tissue is going to recede and then it looks like hell.”

Broken or cracked teeth also point to problems with a person’s bite that a good cosmetic dentist will correct rather than cover up. Addleson turns away patients who don’t want to address oral health problems. Moats does the same.

“I had a woman in here, she wanted six veneers,” Moats says. “I said, ‘No problem, but your bite is wrong. If we don’t correct that first, whatever work I do will break.’ She didn’t like what I said, went to another dentist and came back several months later with broken veneers.”

In extreme cases when a patient needs full-mouth reconstruction, Progebin recommends consulting a prosthodontist. “The specialist acts like a project manager,” he says. “There’s got to be one person in charge. I’d send you to the orthodontist. I’d send you to the periodontist or oral surgeon. I’d coordinate [dental care] for you.”

Vonderau says he feels like Addleson is interested in his oral health, not just expensive procedures, because the dentist declined to whiten one of his teeth. “It’s had a root canal and he would have to drill into the tooth to do an effective bleach,” he says. “It would weaken the tooth too much. He’s a perfectionist and that’s good."

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It is really a good thing to think that a certain individual like Labbad who have had a bad experience at the dentist was still convinced to see the dentist and undergo several dental services. The cost for restoring back the bright smile and good health for this person was really worth it. Although we know that dentistry is a though job, the fact cannot be denied that dentists play a big role to overall health of each individual. I also completely agree with the fact that dentists need to look at the health of the mouth first before any cosmetic dentistry is done.

As a baccalaureate-trained hygienist (WVU School of Dentistry) married to a general dentsit who is retiring after 37 years in practice, I heartily concur with Dr. Rauvola.. far too many practitioners advertising themselves as "Cosmetic Dentists" when they have only done rudimentary continuing education and attended a few of the now-many "cosmetic academies" (nice weekend in resort community). We see too many folks who look like they have a mouth full of Chicklets.. far too white for complexion and age. And, as mentioned, some times cosmetic desires deny the poor foundation of periodontal disease or orthodontic considerations. ANY experienced general dentist with a good lab technician should be able to execute needed cosmetic procedures. As with anything, practice makes perfect. Find an experienced dentist who does NOT advertise him or herself as "an expert" The truly good ones don't need to advertise... word of mouth beats the magazine or newspaper ads. I think it is great that Angiels List addressed the subject and pointed out that it is NOT a recognized specialty. Prosthodontists actually have that distinction, as you point out. And any prosthodontist or good experience dentist will consider oral health first... and customize any needed or desired cosmetic procedures.

Other than an advertisement for Larry Adelson, I don't see much value in this article. I am a prosthetically trained general dentist, who taught clinical prosthodontics for 5 yrs as an assoc. professor at the Univ. of Pacific School of Dentistry, and have been in private practice for 19yrs. It is misleading to the public to say things like, "Without regulation, the public has to ..." as if regulation is what we need, OR implying that the ADA should include cosmetic dentistry as a speciality. That would be absurd. I have never viewed myself as a 'cosmetic dentist' but would surely put my cosmetic procedures against anyone's. When people ask if I am a cosmetic dentist, I honestly reply that I do a lot of cosmetic dentistry everyday, but only if its indicated and only on the teeth that need it. Often times, treating one tooth can change a person's smile completely. "Cosmetic dentists" have unfortunately turned a corner toward the 'dark side' in attending their meetings and listening to their speakers and commonly treat 16-20 all at once in the name of smile therapy. My advise to the consumer would be to NEVER let a dentist drill on a tooth that is other wise healthy in the name of cosmetics--there is always something else that can be done, like bleaching and/or orthodontics. It is 'easier' to match the shade on 16-20 teeth but doesn't require any special skill to have a lab technician do so. Skill is required to restore one or two front teeth that really need it, drastically improving the cosmetic appearance without over-treating. Minimal intervention is still a goal, believe it or not. Every restoration has a lifespan, and unless its a gold onlay (Tucker method) its not going to last 30+ years. Yes, people should find a dentist that has examples of their own work, and also is going to be there for the long haul, establishing a relationship of trust over time. Cosmetic dentistry is not and should never be considered a subspeciality, as it implies that there are dentists that only do non-cosmetic work (?!) (I have to laugh when I say that because unfortunatley it has a bit of truth, but that's another subject!) Scott Rauvola, DDS

The reader should be aware that "Cosmetic Dentistry" is not an ADA recognized specialty. There are Academies of Cosmetic Dentistry but a Dentist would be misrepresenting themselves as "Specializing in Cosmetic Dentistry." In some state, they would even be breaking the law. As advised in the article, the patient should do his/ her homework prior to initiating any procedure with any practitioner. The overwhelming majority of practitioners, both specialists and generalists, are completely honest and trustworthy. They only have the patients best interests in mind. Just like in any profession, there are those that are more interested in padding their wallet than doing no harm. The patient just doesn't know which one they have until things are completed.

I recently had an old bridge replaced with 2 implants. Before going to a periodontist I checked with some friends who both recommended my periodontist and I checked Angie's List and there he was. He was wonderful. He was upfront about the costs and did a wonderful job on the implants and pulling a tooth in the same appointment. He then called me himself the next day to check on me. It has been a month and I am healing just fine. Dr. Michael Arzouman is the way to go. Watch out for quacks who give prices that are too good to be true......because they usually are.

Dentistry is a tough job, and doing esthetic or cosmetic dentistry is even harder. I have been working in the area for a long time, and have found it really hard for some people to understand all of their options and ramifications of treatment. Find a reputable dentist, see if you like him and feel like you can trust him/her and check them out! Interview your dentist, not just on costs, but on their philosophy and values!

Emphasis on health first. Too often I see patients after the fact to clean up the mess. Aesthetics are important but take a second seat to establishing health.

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