New Business for Dentists: Fixing Botched Cosmetic Work
The latest trend in cosmetic dentistry isn't a new kind of tooth-bleaching product: It is fixing other dentists' mistakes.
Americans' desire to have the perfect smile -- spurred by reality "makeover" shows that follow an individual's physical transformation through a variety of cosmetic surgeries -- are resulting in a wave of dental catastrophes, say dentists who repair the botched work.
Since the American Dental Association doesn't recognize "cosmetic dentistry" as a specialty, dental school graduates automatically are licensed to perform cosmetic procedures. Additional training isn't mandatory the way it is for other specialties such as orthodontics.
"I sit in my practice and wait for 'the corrections' to walk in my door," says Donald Missirlian, a San Francisco dentist for more than 40 years.
A 54-year-old woman, unhappy with her initial dental work (top), got a new overhaul (bottom).
Cosmetic dentistry is difficult to define because many of the procedures blur the line between the purely aesthetic and the practical. Procedures that are considered cosmetic range from bleaching to attaching porcelain covers to the front of teeth. Yet some patients without dental problems are opting for crowns -- in which a dentist grinds down an existing tooth to attach a cap -- to cosmetically change a bite (which usually is corrected with braces when it is an orthodontia problem).
Cosmetic procedures, which typically are performed to improve the color and shape of teeth, are risky and can cause permanent damage to teeth, roots and gums if done incorrectly. If a crown isn't cemented properly, for instance, infections can result.
Ronald E. Goldstein, an author of cosmetic dentistry textbooks and founder of the American Academy of Esthetic Dentistry -- which isn't affiliated with the ADA -- estimates that half of the $70.3 billion spent annually on dental work in the U.S. is related to cosmetic procedures. Of that, the Atlanta dentist says, redoing other dentists' shoddy work and misdiagnoses accounts for $10 billion of that. Several other academic dentists back the estimates.
"For the patients, it's a problem -- how do you determine who the best cosmetic dentist is?" says Larry Addleson, president of the American Academy of Cosmetic Dentistry (AACD), a group also not affiliated with the ADA. He says 15% to 20% of the patients in his San Diego practice are victims of poor work.
Eric L. Fugier says that at least half the clientele at his Hollywood, Calif., practice come with botched jobs he fixes. For Robert Vogel, a Manhattan dentist who works on celebrities such as Madonna and Nicole Kidman, it is upward of one-fourth.
Some dentists who sweep up after their colleagues' poor work blame inexperience or the temptation to lure patients into costly procedures. Others say that as more cosmetic procedures are performed, the number of mistakes rises.
Experts say that even though further training isn't mandatory, practitioners should take it upon themselves to boost their education. "To do an entire mouth restoration and crowns is usually out of the scope of recent graduates without more continuing education," says Dennis Tarnow, professor and chairman of implant dentistry at New York University's College of Dentistry.
For-profit companies offering "continuing medical education" charge dentists as much as $10,000 a course, and business is booming. The Las Vegas Institute for Advanced Dental Studies, for instance, is teaching 600 dentists this year, compared with just 200 four years ago.
LVI also offers courses in financial strategies, such as "The Dental Concierge -- Developing a CA$H Practice," according to its Web site. Some dentists are critical of LVI's commercial bent. "They give the wrong message to the dentist that it's OK to grind down teeth and sell the patient that their life is going to change and improve," says Simon Gamer, a dentist in Beverly Hills, Calif.
LVI founder and Chief Executive Bill Dickerson disagrees, saying the school trains dentists to be professional and to handle "any situation that comes to the office. We tell them to diagnose the patient's mouth as if it were your own."
Makers of cosmetic-dental products and laboratories supplying goods to cosmetic dentists say their businesses are expanding at double-digit rates. Da Vinci Studios Inc., a West Hills, Calif., lab that customizes veneers and crowns for 1,500 dental practices -- and whose veneers are featured on the "Extreme Makeover" and "Swan" reality shows -- says sales rose 25% last year. MicroDental Laboratories Inc., a Dublin, Calif., lab, had $23 million in revenue from porcelain veneers last year, up from $12 million in 2000.
Patients are paying thousands for a million-dollar smile. Veneers and crowns can range to as much as $4,000 a tooth, and in-office whitening can cost as much as $1,000. That compares with $50 to $250 a tooth for conventional procedures such as cavity fillings.
As a result, dentists' incomes are soaring. Their average annual income was $173,140 in 2001, the most recent year for which figures are available from the ADA, up from $133,430 in 1997. Larry Winans, a 39-year-old Lewisburg, Pa., dentist who took courses at LVI, says he went from earning about $100,000 in 1999 to more than $200,000 today, mostly because of increased business in cosmetic work.
Dentists learning cosmetic procedures sometimes turn to colleagues for instruction. Malcolm L. Henley, an Orlando, Fla., dentist who has practiced for nearly 45 years, wrote in March on the AACD's online forum: "My veneer seating technique is, to say the least, not a fun experience!" He says glue removal for veneers is "a bit horrific. Can anyone advise a source to improve my results?''
William Dorfman, a Century City, Calif., dentist who is featured on "Extreme Makeover" and who sees 200 new patients each month, says their "dental IQs have skyrocketed" since the show began because now they are aware of the kinds of cosmetic dentistry available.
"In the old days, it took a lot of time to explain the procedures," Dr. Dorfman says. Now, "it's almost like all I have to do is verify what they want done."
Some dentists worry about colleagues who allow patients to dictate their treatment on their limited knowledge, and they urge dentists to offer less-invasive procedures.
Gordon J. Christensen, a clinical professor at the University of Utah and owner of the for-profit, continuing-education Practical Clinical Courses in Provo, Utah, says a "degeneration of ethics" has made his profession "highly upset."
Dr. Christensen, who has served on numerous ADA councils, says the onus to halt the rise of botched work falls on the ADA, which can recommend additional guidelines for cosmetic dentistry to state and local dental associations.
The ADA, which represents the vast majority of the more than 155,000 U.S. dentists and advises the dental boards of each state, believes current ADA guidelines and state regulations provide "sufficient oversight for the protection of the public," says Matt Messina, an ADA consumer adviser and a dentist in Cleveland, Ohio.
Dentists say it also is up to patients to check their dentists' credentials and complaint records with their state dental board and county dental association, ask about more conservative treatments, and get second and third opinions before major work.
牙齿美容缺憾多 成就牙医新生意
眼下，牙科美容行业的最新潮流可不是什么新的牙齿亮白产品，而是如何补救其他牙科美容医师留下的败笔。
修补这些败笔的牙医们称，一些身体力行作过美容手术的人纷纷在电视上现身说法，鼓舞了美国人对完美笑容的热烈追求。不过，这正在引发一场牙医行业的灾难。
自从美国牙医协会(American Dental Association, 简称ADA)不再将“牙科美容”视为一项医学专科后，牙科医学院的毕业生们便可自动获得牙科美容术的从业资格。从事牙科美容，无需再像牙齿矫正等医学专科一样必须接受进一步的培训。
“每天，我只需坐在办公室，等著那些需要纠正牙科美容败笔的患者上门，”行医40余年的旧金山牙医唐纳德?米西利安(Donald Missirlian)称。
牙科美容实际上很难定义，纯粹追求美和具有实用价值之间的界限有时很模糊。被认为属于牙科美容的手术包括漂白、镶瓷等。但一些没有牙科疾病的患者也会选择安装牙冠，来美化牙齿；而在矫正牙齿畸形时，牙医通常会安装牙套来达到美化的目的。
美化牙齿颜色和形状的手术通常都有风险。如果操作不当，可能会给牙齿、牙根和牙龈带来永久性的损害。例如牙冠若不能准确密合，就可能导致感染。
牙科美容教科书的撰写者、美国审美牙科学会(American Academy of Esthetic Dentistry, 简称AAED)的发起人罗纳德?戈德斯坦(Ronald E. Goldstein)估计，美国人每年用在牙科上的703亿美元中有一半都和牙科美容有关。这位亚特兰大的牙医称，这其中为补救其他牙医的败笔而花费的数目大概就要达到100亿美元。AAED并不隶属于ADA。学术界其他几位牙科专家也认同这些估计数据。
“患者的问题是，如何确定谁是最好的牙科美容医师，”美国牙科美容学会(American Academy of Cosmetic Dentistry, 简称AACD)的主席拉里?阿德森(Larry Addleson)称。AACD同样也不隶属于ADA。阿德森称，他在圣地牙哥行医的过程中诊治的患者中15%-20%都是拙劣牙科美容术的受害者。
埃立克?菲吉耶(Eric L. Fugier)称，他在加州好莱坞的客户中至少有一半都是前来补救失败美容术的。对于为麦当娜(Madonna)和妮可?基德曼(Nicole Kidman)等社会名流提供服务的曼哈顿牙医罗伯特?沃格(Robert Vogel)来说，这个比例在1/4以上。
一些牙医在修补了同行的拙作后表示，问题的根源在于缺乏经验，或受经济利益诱惑，在条件不成熟的情况下鼓动患者实施价格昂贵的牙科美容术。但也有人认为，失误数量上升与手术数量增加是分不开的。
专家们称，即使法律没有规定一定要接受进一步的培训，从业者也应主动进修。纽约大学牙科学院(New York University's College of Dentistry)植入式牙科手术教授丹尼斯?塔诺(Dennis Tarno)称，刚毕业还没有进修过的学生要进行全面口腔修复和牙冠手术操作还欠火候。
提供医科继续教育的营利性公司就每门课程向牙医收取高达1万美元的费用，报名人数还在不断增加。比如，拉斯维加斯高等牙科学院(The Las Vegas Institute for Advanced Dental Studies)今年就招收了600名牙医学生，而四年前才只有区区200名。
该校网站显示，学院也提供相关的财务策略课程，例如《The Dental Concierge -- Developing a CA$H Practice》。一些牙医对该学院的商业化倾向颇有微词。加利福尼亚州贝弗利西尔斯的一位牙医西蒙?加梅(Simon Gamer)称，他们向牙医们传递了一个错误信息，即可以向患者兜售牙科美容可以改善人生的概念。
对此，拉斯维加斯高等牙科学院的创立人兼首席执行长比尔?迪克森(Bill Dickerson)并不同意。他说，学院培训牙医的专业水准，使他们能处理门诊中遇到的任何问题，同时也传授设身处地为患者著想的理念。
牙科美容产品的生产厂家，以及为牙科美容医生提供产品的实验室均表示，他们的业务在以两位数的速度增长。加利福尼亚州西山的Da Vinci Studios Inc.去年销售额增长了25%；这家实验室为1,500家牙医诊所提供定制的瓷片和牙冠，产品频频出现在《绝对重生》(Extreme Makeover)和《丑小鸭变天鹅》(Swan)等纪实秀中。加利福尼亚州都柏林的一家实验室MicroDental Laboratories Inc.去年瓷片的销售额为2,300万美元，大大高于2000年的1,200万美元。
人们情愿为完美笑容一掷千金。瓷片和牙冠的价格能高达每颗牙齿4,000美元，在诊所漂白牙齿的收费能高达1,000美元。而补牙等传统牙科手术的收费只有每颗牙齿50-250美元。
因此，牙医的收入会因牙科美容术而大幅增长。根据从ADA可以查到的最新数据，2001年牙医的平均年收入为173,140美元，较1997年的133,430美元有大幅增长。
今年39岁的宾夕法尼亚州刘易斯堡牙医拉里?温纳斯(Larry Winans)曾在拉斯维加斯高等牙科学院学习。他表示，他的收入已从1999年的10万美元左右升至今日的20万美元以上，主要是因为牙科美容业务的增长。
学习牙科美容术的牙医们有时会向同行讨教。佛罗里达州奥兰多的牙医马尔科姆?亨利(Malcolm L. Henley)已有近45年的行医经验，3月份他在AACD的网上论坛写道：“我给牙齿贴瓷片时怎么著都不轻松。去除胶水很麻烦，有谁能告诉我如何改进？”
加利福尼亚世纪城的牙医威廉姆?多尔夫曼(William Dorfman)曾出现在《绝对重生》节目中，每月接诊200位新患者。多尔夫曼称，自从这类纪实性电视节目开播以来，患者的牙科智商有了大幅提高，他们对现有的牙科美容术了如指掌。
“过去我要花很多时间来解释手术过程，”多尔夫曼表示，“现在，我要做的似乎就是从专业的角度来确定他们的想法是否可行。”
但患者的牙科知识仍然很有限，因此一些牙医对其他同行允许患者自行决定治疗方法的做法感到担心，他们敦促那些同行向患者提供一些损伤程度较轻的方案。
犹他州大学(University of Utah)临床学教授戈尔丹?克里斯坦森(Gordon J. Christensen)称，“职业道德感的普遍下降使得这个行业非常令人沮丧。”克里斯坦森同时在犹他州普罗沃拥有一个营利性的继续教育机构Practical Clinical Courses。
曾多次入选ADA理事会的克里斯坦森称，喊停拙劣牙科美容术的重任落在ADA的身上，ADA可以建议美国各州和各地的牙医协会为牙科美容行业制定更多的指导性规定。
ADA消费者顾问、俄亥俄州克利夫兰牙医马特?马西纳(Matt Messina)表示，ADA相信，目前的ADA指导性规定和各州的法规为保护公众利益提供了充分的监督机制。ADA代表了美国15.5万多名牙医中的绝大多数，负责向各州牙医协会提供建议。
牙医们称，这也要取决于患者的态度。患者们可以在州和县牙医协会处核查牙医的资格和投诉记录，询问更为保守的治疗措施，在作大手术前多方听取意见，三思而后行。
