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Second Opinion: The "Daughter" Test Dr. Dan E. Fischer

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Dr. Fischer (left) and Dr. Jaleena Jessop
The “Daughter Test”
The Most Important Test for Elective Cosmetic Dentistry

by Dr. Dan E. Fischer

We see patients from every walk of life. One constant feature seems to be the drive for aesthetics and quality of life, particularly with regard to their “smiles.” As clinicians, we face real challenges in keeping up to pace with fashion and technology and weighing these options sensibly against the needs and demands of our patients. The real question often becomes, “What’s the correct option, or the one which will truly meet the needs of my patient and keep me from losing sleep at night?”

Dr. Martin Kelleher*, Consultant in Restorative Dentistry at Kings College practicing in the United Kingdom, appropriately identified this dilemma (In the January/February 2010 issue of Dental Update) as the “Daughter Test.” In any instance where a cosmetic dilemma presents itself, he suggested the following consideration or “test” prior to proceeding with any potentially destructive treatment plan:

“Knowing what I know about what is involved in the long term as a consequence of this proposed elective dentistry, would I carry out this treatment on my own daughter’s teeth?”

He suggests a change in the proposed treatment plan if a negative response should be the answer.

It’s quite simple, actually. Not only does the “Daughter Test” consider the health of the teeth and the patient in both the short and long term, it also places the responsibility of human care back into the hands of the responsible clinician. Solutions that pass the “Daughter Test” result in improvements to the patient’s smile while maintaining the optimum level of the patient’s dentition.

I was reminded of one of my experiences with the “Daughter Test” upon reflection of the history of Opalescence. When my own daughter, now Jaleena Jessop, DDS, was 14 years old, she faced challenges with children her own age because of her slightly “yellowish smile.” I’ll never forget how determined she became to achieve a whiter smile. She would show me ads from my dental journals of the 1980s on technologies such as an early bleaching light used with peroxide. She even showed me articles and advertisements on veneers. I told her to be patient because I was working on something that would help. That “something” became what is known as Opalescence.

It was a simple decision for me; a decision that meant I was only considering the solution that was the absolute best for her.

At the point of the commercialization of Opalescence, tooth bleaching became an integral part of my practice and an important component of Ultradent’s product family in 1990 and beyond. In addition to raising aesthetic awareness, the invention enabled dentists alike to change large numbers of people’s lives while keeping their precious enamel. It was a great opportunity to change people’s lives with a minimally invasive procedure that would even pass the “Daughter Test.” And yes, as so many of us came to learn, as a side benefit it grew our practices in ways that would be good for both our patients and ourselves.

In continuing the arguments for the “Daughter Test,” Dr. Kelleher notes the curious absence of the “porcelain deficiency disease” in the daughters of dentists. Dr. Kelleher puts clinicians to the test by saying that some have been slow to recognize the fact that, with or without bleaching, bonding with direct composite is biologically smart and produces more than acceptable results in the majority of cases. There is good evidence that many wear cases can be dealt with very effectively by this technique and direct composite restorations have distinct biologic advantages, perform well and are associated with a high degree of patient satisfaction. Sadly for the profession’s image, the tendency has been towards more aggressive treatment, which we would not advise our own daughters to undergo.

Repairability of restorations, leaving sound tooth tissue for the future, is sensible, practical and ethical. Our tendency for total replacement of restorations has contributed to the cumulative trauma and even the death of teeth. New technologies, including those that enable quality repairability provide economic and caring “patient-centered” directions for modern operative dentistry. Furthermore, repairability often enables us to provide treatments at a lower cost to more patients, providing us with the ability to reach lower income groups and still maintain profitability. And, as we come to understand the fabulous potential for non- compromising and quality adhesives, we also discover that this is precisely the type of dentistry we’d prefer for our “daughters.” As dentists, we understand that the more we cut teeth, the more we weaken them and cause eventual loss of vitality and structural strength. Dr. Kelleher continues in his article, “Sadly, some superficial, self absorbed, unwitting or easily influenced dentists are seduced by short-term profits and patients’ short-term gratitude for providing a pleasing appearance by undertaking destructive procedures to replace sound enamel and other hard dental tissues with porcelain veneers or porcelain veneered on to various frameworks and copings.” In tackling these individuals in public, or in private, as to why they destroy sound tooth tissue to undertake these aesthetic restorations, it is sad to note that many such dentists tacitly agree that this type of destructive treatment is not what they would do for their own daughter.”

Dr. Kelleher calls attention to the “fashion” in dentistry to provide the patient with whatever they request with many dentists shrugging off the “breathtaking, cavalier destruction of teeth” associated with this. He goes on to say that curiously and perversely there is “higher added value” (i.e. more profit) for the dentist who does a destructive procedure rather than one who does a preventive or constructive procedure.

Even when such short-term income is produced, it will often fizzle in the longer term. Additionally, in many cases where the “top line” may be high, the bottom line can be lower than when less invasive procedures are embraced. I’ve learned from experience that one can actually be more financially secure and with a great income by applying the “Daughter Test.” This is often due to patients understanding that their dentist truly cares about them and wishes to do the right thing for them at all times. Even in a down economy, such trusting patient-dentist relationships continue to lead to continued productivity including such patients referring like-minded friends. Minimally invasive dentistry (including an emphasis on prevention), bleaching and direct bonding represents an alternative method of thinking and acting in dentistry. It is one that requires creativity, skill, and most of all, a consideration of how one would care for one’s own daughter being the standard to be applied equally to other people.

*Footnote from Dr. Fischer: In 1998, Ultradent Products with our UK distributor came to realize we would need to bring litigation against the British government on the subject of tooth bleaching. Dentists had been warned that if they bleached their patients’ teeth (and even with something proven to be as safe as our Opalescence, 10% carbamide peroxide and even though certified by a German authority to be sold throughout all of Europe) they could be fined up to £5,000 and imprisoned for six months. We obtained some of the most knowledgeable experts in UK to help support the scientific and clinical arguments in court. Sadly, these experts bowed out on what appeared to be pressure from UK authorities. Dr. Kelleher was the exception. He stood up gallantly and rightfully to help present valuable knowledge on the importance of safe and predictable tooth bleaching for patients in the UK. Together, we shared with the Court the importance of preserving once-in-a-lifetime enamel, improving smiles and for ultimate care and respect to the patient. Dr. Kelleher was a champion then and he continues to be so now.
Author's Bio
Dr. Dan E. Fischer, founder of Ultradent Products, is a 1974 graduate of Loma Linda University. He lectures around the world on the subject of Minimal Invasive dentistry and reaching more social economic groups via maximizing the possibilities of simplistic modern dental technologies. He still practices part time.
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