Assessment in aesthetic dentistry: A psychological perspective

11 April, 2019 / indepth
 Dr Rebecca Crawford  

In our modern society, peer pressure to have the perfect appearance ensures there is a constant demand for cosmetic procedures. So is it really necessary? And how do you look after the wellbeing of your patients? 

Words: Dr Rebecca Crawford, Consultant Clinical Psychologist

The field of aesthetic procedures is now a multi-million pound industry with demand increasing every year. Societal norms and pressures regarding appearance mean that having cosmetic procedures is now viewed as mainstream and acceptable.

it is okay to say no if you do not feel treatment is appropriate. Do not ignore your instincts. If it feels risky or uncomfortable then no is probably the right answer

This demand may bring lots of opportunities for dental professionals providing aesthetic dental procedures; however, it also brings risks.

So, how do you select the right treatments and the right patients? How do you look out for the psychological wellbeing of your patients and yourself?

Question time

Remember that appropriate patient selection is just as important as technical ability in achieving an outcome that the patient is satisfied with.

Ask the person about what their concerns are… then listen

This sounds very simple, but it is really important to listen without jumping in. Do not start any clinical assessment or discussing your opinions at this stage. Try to remain neutral and ask the patient to tell you more about their views of the problem physically and aesthetically.

Ask them to be very specific and describe their concerns in detail – keep listening and do not jump in with clinical assessment

Beware of people being vague or saying they dislike ‘everything’ about their teeth or appearance. We know that people are more likely to be satisfied after treatment if this has addressed what they were concerned about. Again this sounds simple, but there is a difference between this and a clinically excellent outcome as assessed by the clinician. It is essential that you elicit and understand fully what a person is bothered about in order to address this in treatment planning.

When did the person first notice the things they are concerned about now? Has this been something that they have always been aware of or has something changed recently? And When did they first become concerned about it?

These are different questions! 

Someone may have noticed something about their teeth for many years, but not felt that this was negative or felt the need to pursue any treatment for this. Did they become aware of it or has somebody else pointed this out or suggested they required treatment? Try to establish if the timeline for the person becoming concerned about their teeth. Again try to gather detailed information regarding what specifically is bothering them and why. Ask about any impact they feel this is having on their life and their psychological wellbeing. Make sure that they are not feeling under any external pressure from a third party to alter their appearance.

Why now? What has made the person decide to seek treatment at this point in time? 

Watch out for any major life events or negative trigger events that seem to have prompted either dissatisfaction with their appearance or a decision to seek treatment. These may mean people are not in the best position to be making treatment decisions or sticking with a treatment plan at this stage.

Hopes and expectations 

Ask the person what they hope will be different after treatment. This needs to be explored in terms of how they are expecting their appearance to alter, any changes to physical functioning and how they think this may impact
on their life and psychological wellbeing generally.

So, now you have done all of this you can begin your clinical assessment regarding their teeth. Do this as usual.

Assessment

Before feeding back to the person about any proposed treatment consider the following points:

Consider your clinical examination and the information you have gathered about the person’s perception of the problem. Is there a discrepancy between your view and the patient’s view or are they fairly similar? Does the person have a disproportionate view of the problem?

Beware if there is a large discrepancy between your examination and how the person views their teeth, and if their view is that their clinical presentation is much worse that your examination. As previously mentioned, we know that people are more likely to be satisfied after treatment if this has addressed what they were concerned about. However, if what they are concerned about is disproportionate and their perception is not in keeping with your physical examination, it is highly unlikely to be resolved by treatment.

Consider the person’s expectations regarding the physical and aesthetic outcomes they are hoping to achieve. Do you think these are possible and realistic now you have completed your clinical examination? If not, why not? Now think about their expectations regarding the impact that the outcome may have on their life and psychological wellbeing. Is this realistic? 

Remember that there is very little robust long-term outcome data regarding the impact of aesthetic dental procedures on psychological functioning and wellbeing. Also for people with significant psychological difficulties, aesthetic dental procedures are certainly not evidence-based treatments for these. We appreciate that you are running a business, but please be honest and realistic with yourself and the patient about what can be achieved. If you get this right at the beginning people are far more likely to be satisfied at the end of treatment. With the rise in demand for aesthetic procedures comes ever increasing expectations regarding what is possible, so please be cautious with what you promise.

Next steps

How do you feel? This maybe sounds like the sort of question you might be expecting a clinical psychologist to ask a patient? But I am asking you!

Do you feel under pressure to make a decision quickly? 

Do you feel pressured to offer something that you would not usually do clinically or that is out with your range of competence? Has this person been to see multiple clinicians or been to see you many times requesting treatment?

Be aware of persistence and pressure to proceed. Try to tune into this during your appointment if you feel pushed to do something, put the brakes on and consider why. Some people can make you feel very pressurised
to agree to a treatment plan, this should always be a cause for concern. Treatment of this sort should be carefully considered and planned; it is never ‘an emergency’ or ‘urgent’.

Gather further information. GMPs are a fantastic source of information. If patients are complex and you have concerns, request consent to gather further information from their GP and discuss their treatment request. If people are very reluctant to agree to this – again beware – try to discuss why they might not want their case discussed; this is about their overall wellbeing, psychological and physical, so it is very important.

Consult your colleagues. If there are any aspects of a case that raise concern or you feel uncertain about, discuss things with your dental colleagues. This can also be very helpful for cases where you feel pressure to proceed;
to reflect on the case with an impartial colleague can bring a different perspective and help you consider the most appropriate way forward. 

Saying no! If you have gathered all of the information and considered things carefully, it is okay to say no if you do not feel treatment is appropriate.

Do not ignore your instincts. If it feels risky or uncomfortable then no is probably the right answer. This may be for a variety of reasons.

Communicate clearly. Explain to the person what the proposed plan is, what this will and will not achieve functionally and aesthetically, time scale, possible risks and complications, the importance of realistic expectations regarding long-term outcome etc. Check if that is what they would like to proceed with, whether they need time to consider it and do they require further information. And if your answer to treatment is no, or not at the moment, try to communicate this sensitively but clearly and explain why, be firm about your decision and do not make any last minutes changes to this based on pressure from the patient.

Patient-centred decision

Many of these tips may seem relatively simple – that is because they are – and they should all be things that you can incorporate into routine practice. 

It is also important to note that while these tips will assist with appropriate patient selection this does not replace expert psychological assessment in any way and this may be required for some complex patients.

So initial assessment might sometimes take you a little longer, you might need to consult with colleagues a bit more often, you might say no to a few people, but hopefully the patients you do select will reach a collaborative, patient-centred decision with you, be satisfied with what you achieve, and your own psychological wellbeing will remain intact.


Case studies

What are the clinical implications of a patient’s desire to ‘look perfect’?

Case A

Patient A attends for an initial assessment appointment with you. On first impressions you feel that there presenting problem is in the mild range. You use all of your new skills – as detailed on the previous pages!

The person explains to you that they feel their problem is very severe and worse than anyone else they have ever met. They are very vague about what specifically concerns them but ‘hate everything about their teeth’ and would like you to ‘just sort it out’ so that their teeth look ‘perfect’.

They explain that they have been concerned about their teeth for many years but have decided to pursue treatment now as they feel worse about their teeth; however, they are unclear about why and mention that the appearance of their teeth has not changed. They hope that you will be able to make them ‘beautiful’ and that they will feel happier and more confident as a result. They feel their whole life will be different, in a positive way, if their teeth were altered.

They also mention that they have already a number of other clinicians about this, but all of them have declined treatment. The person feels this is because these clinicians do not really understand their concerns properly, and they are hoping that you will be able to because they are not sure what they will do next if you decline treatment too. They are very keen for you to make a decision today, as they do not have time to waste and will need to see someone else if you are not willing to do it.

Consider all of your points – what would you do?

Disproportionate concern, which is vague and out of line with your clinical examination. Unrealistic expectations of what any treatment will achieve physically and psychologically. Persistence and pressure to proceed. All of these points are leading you to conclude that treatment is not indicated. Although the presenting problem may seem mild from a physical point of view with a simple low-risk solution, managing the psychological aspects of this case mean that it is likely to be complicated with a high risk of the person being dissatisfied with the end result.

Case B

Patient B attends for an initial assessment appointment with you. On first impressions you feel that the presenting problem is in the moderate to severe range. You use all of your new skills – as detailed above!

The person explains to you that they feel their problem is quite bad. They are specific about what concerns them and have brought a list with details about this, and the impact they feel teeth are having on life. They explain that they have become increasingly concerned about their teeth in the last few years but have decided to pursue treatment now as they have the financial means to do so.  They hope that you will be able to discuss some treatment options for them to consider, but are happy to go with whatever you think is best.

During the assessment the person is very agitated, finding it difficult to make eye contact, and struggles to articulate all of their concerns to you. They mention that they find it very difficult to meet new people and have been very worried about coming to their appointment today. They have prepared by writing things down and taking their medication, as recommended by their GP. They are hoping that treatment for their teeth will improve their confidence and self-esteem and make them less self-conscious about their appearance.

They also mention that they were previously very concerned about the appearance of their nose and have had cosmetic surgery privately. They feel that this did address their concerns about the appearance of their nose. They acknowledge that this did not have the broader impact on confidence and social functioning that they were hoping for.

Consider all of your points – what would you do?

Unrealistic expectations of what treatment may achieve from a psychological perspective. Previous cosmetic surgery which has met physical but not psychological expectations. Overt signs of anxiety at assessment. Mention of medication and GP awareness of these difficulties. All of these points may lead to you to feel that you require further information about this patient and to discuss the case with the GP. If the person has significant difficulties with anxiety these will not be resolved by having dental treatment. Although the presenting problem is moderate to severe from a physical point of view, do not let this cloud your judgement or discount the psychological aspects at play here. Managing the psychological aspects of this case and considering these in any suggested treatment plan are essential in reaching a collaborative plan, at the right time, with realistic goals for outcome psychologically and physically.

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