In the last few years, it has become clear that the UK has seen a huge increase in the amount of patients wanting aesthetic dentistry. This may be down to a number of factors – a couple being the explosion of social media, and quite possibly added to by the Covid pandemic changing people’s perception of themselves and healthcare.
A common treatment option patients request is Invisalign treatment for the obvious benefits of straighter teeth, with the bonus of a subtle treatment appearance in contrast to fixed braces. Another common treatment is composite bonding for the benefits of changing the shape of their teeth, often with the perceived idea it’s a more economical alternative to porcelain veneers and less damage to the underlying tooth structure.
Unfortunately, however, social media will often only show the ‘good sides’ of people’s lives, and patients may misunderstand how these two treatments may need to work hand in hand in an ortho-restorative approach. They are often ill-informed about the maintenance long term and it’s important, as dentists, that we provide them with realistic expectations of their commitment, and maybe become more selective about who we do and don’t treat.
The likes of Instagram, Facebook, and TikTok (the list goes on) have exposed the world to the idea that ‘perfection’ is easily achievable. This can be seen with influencers presenting a ‘smoke screen’ of their lives – perfectly dressed, high-class holidays, supercars and now on top of that – ‘the perfect smile’. In my practices, this is seen every day with patients enquiring about ‘composite bonding’ because they have seen someone on Instagram having the same treatment. It seems so simple to them – one appointment and they leave with the ideal smile which is going to last forever… Right? Some patients feel that whatever their dental health is like, whatever malocclusions they have, they can still come into the surgery and leave a few hours later with that ‘insta smile’.
Another presentation is the patient wanting Invisalign treatment, thinking that this will not only straighten their teeth ‘in three months like their friend’ but somehow fix the years of damage caused by malocclusion, neglect and tooth-wear.
It’s our job as dentists to fully inform these patients that it takes a bit more work than they often expect, but more importantly comes with life-long maintenance.
Patients can now easily access thousands of dentists just with a few clicks on social media. I could show you hundreds of messages on my Instagram (@georgethedentist) from patients introducing themselves with – ‘how much is bonding’ or ‘how much is Invisalign’. I can also tell you these are probably the patients you want to avoid.
I sometimes think we add fuel to the fire by providing free consultations and can give in to patient pressures to side with a particular treatment they want, even if it’s not what we would call ideal. I get it though – there’s the temptation to get the patient in the chair to sign them up for treatment, as from a business perspective it makes sense rather than they go to another clinic where they offer free consultations. Doesn’t it? Well in my personal clinical practice, I disagree, I dropped the ‘free consult’ a long time ago – as it attracts the patients who want a completely standardised package, for a standardised price, and don’t understand why the treatment may be more expensive for one patient than their friend. Whereas if a patient is paying for their consultation, they have probably done their research into the practice’s reputation and ‘want’ to have treatment with you, appreciating the quality of the work. They are therefore going to listen to what you have to say rather than thinking every dentist is just cut and paste out of dental school. They may understand better that bonding isn’t appropriate for them unless there is some corrective Invisalign first.
The issue with these free consults is that the patient will often be visiting multiple dentists (why wouldn’t you?) – and I can understand why it would be easy for a dentist, therefore, to just paint a positive picture of the overall treatment to provide the sell, but what happens when a patient doesn’t end up with their ‘perfect smile which lasts forever’… The unreasonable complaints come in. Often this is because a patient hasn’t been listening to the maintenance instructions before and after treatment, or hasn’t gone for the advised treatment.
Filtering Your Patients
An important part of my ‘cosmetic’ consultation process is selecting the right patient for the practice and filtering out the ones I don’t feel fit in with the practice values, rather than particularly trying to ‘gain a patient’. I would love to treat everyone, but if patients don’t take my advice then the patient-dentist relationship cannot be successful.
I will typically take an iTero digital scan of every patient and spend time communicating to them what treatment I feel is best for their dental health considering what they want to achieve. If they want this ‘Insta smile’ – I feel it’s actually a relatively small percentage of patients that come through the door who JUST require Invisalign, or JUST require composite bonding. A lot of patients come in wanting bonding to fix their toothwear – but if we provide this bonding without fixing the malocclusion that’s caused it, we are going to be setting ourselves up for failure. A lot of patients also come in wanting to straighten their teeth, not realising that they suffer from tooth-wear or asymmetries because the crowding is masking it – therefore are going to need a restorative touch-up at the end of orthodontic treatment.
Gauging a patient’s expectations is key to any successful treatment – I would prefer to lose a patient who creates an unhappy one.
Why Does Bonding Often Come with Pre-restorative Ortho?
The problem with attempting bonding on a patient with misalignment – is that a huge proportion of the tooth has to be covered with composite to create the illusion of straight teeth. There will be areas of tooth with thick composite additions, and areas of teeth with thin areas – which unless you’re an extremely gifted clinician won’t create the uniformity a patient desires. What, therefore, commonly happens is a lot of the teeth receive what I would call a ‘full coverage composite veneer’ which makes it easier to create a uniform appearance. But here’s the brutal truth – the more composite – the more maintenance.
Now I’m not saying a composite veneer is never appropriate, and there are some extremely talented dentists placing a lot of composite veneers. What I am saying is that they can come with a huge amount of issues IF the patient isn’t completely dedicated to an immaculate care routine. This work is naturally going to be more plaque-retentive and harder to clean than a natural tooth, especially if it masks crowding given the unnatural shapes the clinician needs to provide to camouflage the misalignment. There is going to be more composite to stain, which can create periodontal issues, it’s an incredibly technically demanding procedure, and the patient is going to be signed up to having it all cut off and replaced probably a couple of times every decade. This is undoubtedly going to damage healthy tooth along the process. As I gain more experience, I realise I want more of a stress-free life, this is why I’ll pass up treating a patient insistent on composite veneers on misaligned teeth or without a dedication to maintenance.
My experience – on your poorly ‘filtered’ patients who don’t stick to their maintenance regime – however much you warn them of their responsibility, this is a commonly forgotten conversation when they attend with a problem afterwards.
Another question I’ll often receive is ‘why is my friend’s treatment cheaper?’
A common misconception patients present with is that Invisalign and bonding should be the same price depending on the patient’s dentition and whatever clinician they are visiting.
Invisalign can be a confusing place for patients as they often have the perception that ‘the Invisalign system’ does all the work. They are unaware of the planning process that goes on in the clinician’s hands, the length of treatment, and the particular retention regime the practice supplies at the end of treatment.
The Maintenance Discussion
We have discussed ‘selecting the right patients for you’ and in my opinion this is probably the most important discussion during a consultation. Failures cost you time, money and loss of sleep. Everyone (even the most gifted dentists on the planet) who do enough Invisalign and bonding cases – have seen relapse, chipping and staining. From my personal experience, a very strict conversation with the patient at the beginning, during, and end of treatment of treatment, combined with a belt and braces retention regime will hugely reduce these failures.
My conversation will typically include – ‘I wouldn’t recommend Invisalign or composite work on your teeth if you’re not prepared to care for them well. I can do composite bonding on a well-maintained patient and they present years later with the composite looking as good as the day I placed it, and I can do the same on a patient who doesn’t care for it – who then presents months later with chipping and staining. In truth, the composite is definitely going to chip, but the regularity of this depends on your care – I don’t want to be charging you to constantly repair these little chips. You are going to have to reconsider your diet, avoid abrasive foods, avoid biting on things that you shouldn’t be biting on (e.g. your nails, pen lids) and you’re also going to need to wear your retainer every single night without fail’.
At the end of my Invisalign and bonding cases, I will provide fixed retainers on probably 99% of my patients and 3xSETS VIVERA retainers on 100%. This helps me feel confident that if a patient is returning with any form of relapse I’ve done everything I can to keep these teeth where I have put them.
Invisalign and composite bonding is a beautiful minimally invasive solution for the majority of patients who are dedicated to a strict maintenance protocol. We can fix problematic bites, halt the progression of a destructive occlusion, and restore aesthetic results to damaged teeth – which would alternatively take a more invasive approach.
The consultation with your patients is an incredibly important step to gauge expectations and prepare them for the reasoning behind a varying price, expectation management, and very importantly the maintenance protocol afterwards.
Article by George Cheetham