~ chapters on plastic surgery andcosmetology about myapproachto restorative dentistry.

The studies of one of mymentors. Charlie Pincus fromCalifornia. also had an early in-Iluence on me. Charlie startedshaping the mouths of moviestars and realized what It took tomake smiles come alJve. Drs.John Frush and Roland Fishermade significant progress IndescribIng what made realJstlcfull denture aesthetics. Theywrote a series of articles thatrevealed the major points of aes-thetIcs for full-denture prosthet-Ics only. So. I applied these prin-cIples. plus others, to the fixeddentition and made them appli-cable to the human dentition. Ihave always practiced aestheticdentistry from a multI-discIplIn-ary approach. Since my late fa-ther Dr. Irving Goldstein wasmulti-talented In every aspect ofdentistry , he taught me the valuein considering every specialty toachieve the best result.

Orthodontics always playeda major role because of myfather's brother, MarvinGoldstetn. He taught me abouthis specialty of orthodontics andhow Important It was to see theadult patient from an orthodon-tIc and a restorative solution.

So. 30 years ago it was an eye-opening experience for me justto see how we could work to-gether, and we managed to cre-ate many compromised solutionsthat achieved tmproved func-tion plus aesthetics.

When Dr. David Garbercameaboard as a team member, wewere able to go that extra step toget greater aesthetic perfectionfor the patient. In every case, wequestion the patient's smile, andwe ask ourselves. .Is that thebest that smile could be. or arewe able to shape the frame bet-ter?" With David as both aperiodontist and prosthodontist,he Instantly became a vital teammember. Now, we manage betterthan ever to look at the patientfioom an orthodontic, restorative,and a surgical viewpoInt.

We also became better dIag-nosticIans. We look at crown toroot ratio and the amount ofcrown structure visible In thepatient's smile, not only func-tionally. but aesthetically. Davidwas not only able to performthese dIfferent types of periodon-tal procedures. but we were alsoable to vary the amount of toothstructure by shortening or bychanging the angles and usIngorthodontic procedures. We stopat nothing to achieve aesthetic

I perfection for the patient. It Is

rare that we can.t improve a

patient's appearance, and it isbecause of our team approach.

Another valuable part of ourteam are our chief dentallabora-tory technicians. Pinhas Marand Mark Hamilton. We are Inti-mately Involved with a total teamapproach to aesthetics -fromour receptionist, hygienists, as-sistants, and imaging techni-cian to the treatment coordina-tor. Once we have decided whatwe can acWeve based on what thepatient may want. we must con-finn that by having our imagingtechnician produce a visual resulton the computer. "No surprises" isour best chance for success.

I am a strong advocate ofpatient education. Descrlbethe educational process foryom new patients.

Dr, Goldstein: Patient edu-cation must begin before thepatient comes for his or her firstvisit. If we are able to help apatient become more knowledge-able about Ws or her problemand the potential solutions, wehave a much easier task of casepresentation. I would go so faras to say that having an In-formed patient is one-fourth thebattle of successful results. Weaccomplish this by asking the

patient to buy a copy ofQuintessence's Change YourSmile, We have requested vari-ous bookstores to stock thisbook, SO it is convenient for pa-tlentsto pick upacopy, Ifforanyreason they are unable to pur-chase tile book. the bookstorecan send it to them by mail,

Obviously, with this pro-cess you have helped the pa-tlent develop a reeling or seU-discovery or their situation.

Dr. Garber: Yes, we feel thesame way because the book helpspatients view their own prob-lems through photographs ofother patients with similar sce-narios that have been success-fully treated, They might see dif-ferent treatment options offered,such as bonding. crowns. orlaminates, and understand therespective advantages. disadvan-tages. and limitations of poten-tiai treatment alternatives, Ifsomeone comes to our office andwe have to fully educate themabout laminates. we might leaveout some important feature.which could have been a decid-ing factor in the patients deci-sion-making process. This com-prehensive approach is relevant.The patient can ask pertinentquestions. so any concerns canbe answered and costly mistakesavoided. ~gally. wearealsosat-isfying our obligation for in-formed consent.

When patients come to theoffice what further educationis offered?

Dr. Garber: Depending onthe nature of the patient's com-plaint. the docters or auxiliarystaff can discuss the specificproblem with the assistance ofaudio-visual aids. such as com-puter imagIng. Our treatmentcoordinatordtrects much of this.but it usually becomes neces-sary to gather some diagnosticInfonnation to determine whichtreatment approaches are viable.In this process, radiographs areinvariably first.

Berore we go any further,let's review the high-tech ad-vancements in radiographsusing RadioVIsioGraphy.

Dr. Garber: This is certainlyone of the more exciting develop-ments in high-tech dentistry. x-rays are taken and immediatelyprojected onto a 1V screen ormonitor, There is less exposureto radiation and no waiting for

An IntelView With Dr. Ronald Goldstein and Dr. David GarberBy Dr .Hugh F. Doherty. CFPDr. Ronnld Goldstein Is intema- .

tionally acclaimedfor his effortsto bring the benefits of aestheticdentistry to the attention of thedental profession and pubtic. Hehas authored two intemationaUybest selling books. Esthetics inDentistry. a textbook that hasbeen tTWIS/a1ed into .five lan-guages. and Change Your SmUe.a conswner reference guide. Hehas practiced aesthetic dentistryin Atlanta .Ga. for more than 30years. He Is aclinicalprofessorofrestorative dentistry at the Medi-cal College of Georgia School of

Dentistry inAugusta andadJW1Ctclinml professor at Bosm ~ -

sity. w1d a specinl /ectw.,,- in aes-~ denttstJy at Enoy ~-sity &Iro of DenttstJy in Atlanta

Dr .David Garber Is a partnerin the practice of Goldstein.Goldste/n, and Garber. He Is aclinical professor ofprosthodontics at the MedicalCollege ofGeorgia School of Den-tistJy in Augusta and a specIallecturer in aesthetic dentistJy atEmory University School of Den-tistry in Atlanta.

Drs. Goldstein and Garberhave co-authored the textsBleaching Teeth and PorcelainLamInate Veneers.

In part one of Dr. HughDoherty .s interview .the two doc-tors discuss the importance ofpattent education and high-tech

denttstJy.

How do you approach aes-thetic dentistry?

Dr. Goldsteln: I look at aes-thetic dentistry as all encom-passing. Total facial aestheticsmeans everythIng must worktogether for complete patientsatisfaction- More than 30 yearsago. I began dissecting the sub-ject of aesthetic dentistry Intocomponents. In fact. this be-came the basis of my first text-book published In 1976. Esthet-ics In Dentistry (J .B. UppIncottJ .I knew that having a good-look-Ing smile or an attractive facewas much more than just whatwe could do with teeth. So Istudied art. cosmetology. haIr-styling. plastic surgery .and otherrelated areas. This became avital part of the format of Esthet-ics In DentistJy when I published

DEIfI1STRY TODAY. DECEMBER 1991

Vofce.acttvated periDdontal cha11~

need ror slerility. With this type orequipment. there is no excuse notto do a comprehensive charting.For the firsl time we are getting theroutine baseline dala on all or ourpatients

We are also able to procuresequential petiodontal readIngsfoUowinginttial therapyandsurgi.ca1 treatment.Itgives us theabl11tyto see and compare aU the data onthe same chart in different colo",with indlcationsof any subsequentbreakdown. Bleeding or puspoints are seen by the patientsdiagrammatically and graphi-cally. The patient. while goingthrough the process with us.becomes more exctted about thewhole concept. They are fasci-nated as we start talking to amachine. and it answers!

Our patient home care com-pliance has improved exponen-tiaUY because of the visual regIs-tration of where the problem areasare and the fact that they takehome a chart and concentrateon the exact areas. It improvesthe dental IQ of patients be-cause they now can see andunderstand their condition.

On recall. You can show thema foUow-up chart on how they haveimproved. With thevoice-activatedcharting system. we have somedefinitive data to feedback to thepatient which research studiesshow improves maintenancecompliance and health. A com-parative bleeding index can alsobe rapidiy tabulated.

Therapy with the hygienistIs your first consideration. Haveyou made any recommendationsto the patient at this point?

Dr. Goldstein: Yes. we have.Otherwise [ think we would losethe patient. Patients usuaUy cometo us with an aesthetic complaint

it is we are talking aboutFrom another point of view. it

is exciting because aesthetics is sosubjective with imaging. The pa-tient truly becomes a co-dlagnos-tician and a co-theraplst. oltendirecting the treatment acco~to theIr personal emotional needs.

What are some patient re-sponses to images producedby the computer?

Dr. Goldstein: Previously. apatient might look at theIr smileand say. I would like these teethlonger: and you would say. "Youreally could not tolerate a longertooth." With computer imaging.we can show a longer tooth. andthe patient can see for them-selves that It is not going to be aneffective result.

Best of all. we dont get introuble. In the old days, If thepatient requested largerteeth. andwe would make them a longertooth. We could lose all the in\aidcolorization or natural aestheticeffect in the po=lain. because thatis where the incisal blend was. All ofa sudden you end up with unat-tractive. monochromatic teeth.

Another situation would be apatient with a large diastema. Manypatients have the concept that It Isthe space between theIr teeth thatIs unattractive. and as long as youfill that space with a composite.they would be fine. That is notreally true. because quite oftenthat space needs to be dividedbetween four teeth and not justtwo, You need to create a littlemore harmony and not end upwith two big fat front teeth. So.instead of bonding two teeth. wemay laminate four or six teeth,Golden proportion plays a rolehere and our Envision computerhas the aesthetics package builtin. so it makes the final resultautomatic.

Palicnls ncvcr sce themselvesin a lateral or an obliquc view.They nnly see themsclvcs in themirror. so Ihey donI realiz" lor Ihemost thaI theIr smile exlendsbeyond the canines 10 Ihe secondprcmolar. and qujl" o[t"n to thcmt'sial aspt'ct of th(' firsl molar. Iiis nnt ulll.ommon in our a('sthetic('ages 10 incorporalt. 10 leelh,Compulcr imaging mak"s it easierto explain Ihe th" patienl exacllywhy they will not gel lhe beslresull unless 100r 121eeeth are in-l'iudcd. This is all possible withjnsl a photn~raph trom Ih(' ('om.puter imal(ing equipm('nt

Can dentists rely on show-lug patients simulated photosof the end ~t? Me there anypn:cautions in this regard?

Dr. G8Jber: Computer imag-ing gives a patient aJ1 accuratepicture of the net result. They needto know if the picture Is theIr ownpersonal goal for treatment. or iftheystillhavedlfIerentideas. When

I compromises have to be Jnade.can they accept and live with the

processing. Ills an obvious boonin restorative dentistry.endodontics. and implantology .Also. we can take the radiographswe need when trying in a splintedmetal framework or checking theseating of an Implant abutmentwithout exposing the patient tolarger amounts of radiation. If itis incorrect. we can take a sec-ond RadioVisiOGraph toconfinnwithout compromistng the pa-tient. It helps alleviate patients.concerns abou t exposure to whatthey might deem unnecessaryradiation. RadioVisioGraphy Isbeneficial because conventionalX-rays are equivalent to about24 RadioVisioGraphs.

We have found the tntraoralcamera is enonnously helpful inshowing patients any defects tnexisting restorations. I don.tknow a better way to documentmicrocracks. But the real valuein this case is betngable to pho-tograph the diagonal and hori-7.Ontal n1icrocracks for the tn-surance company.

This is one reason we tn-stalled the Fuji Dentacam sys-tem. I really like the large 6-by-8-tnch printout picture. We canbreak up the tndividual toothphotos into one. three. four. orntne per print. It also allows usto input a great deal of tnfonna-tion on the printout concerningthe patient's conditions and ourproposed treatment plan. Itmakes it nice for the patient tobe able to take this photo hometo their spouse or to show theirfliends We can then send an-otherprinttothetnsurancecom-pany. or even keep one tn thefolder for later reference tn con-versing with the patient. I pre-dict every office will eventuallyhave this new technology as partor their routine diagnosis.

What is next in yourpractice's new patient orlen-tation?

Dr. Garber:The patient mayget channeled to a hygienist ifthey need soft tissue or full peri-odontal care. We always like tosee the patients at presentatiOnbefore any treatment is done.This allows uS to gauge the de-gree of home care as indtcatedby the plaque calculus and otherdeblis present. It mayor maynot have initiated an inllamma-tory response. and this gives ussome idea of the patient"s sus-ceptibility to the disease pro-cess. We can then dtrect them tntoan appropliate soft tissue pro-gram rang1ng ti-om a simple pro-phylaxis to six appotntments 01root planing. ThIs gives us time toassess the patient"s complianceand attitude before embarktng onmore tnvolved restorative or peIi-odontal procedures.

We initiate health first in ouroffice. even when aesthetics maybe the patient"s primary con-cern. They do. however, have to Cosnwlic ~ is an 1mporIW11 elemenl of ""' aes"""ic procfice.

, enhances patient co~unication.

or need. Soft tissue managementis phase one of their treatment. Wethink In terms of treatment phasesand don't think In terms of A to z.We have phase one. phase twoandphase three.

Phase one is soft tissue man-agement, treatment splinting Inperiodontal therapy, or orthodon-tics, It could also be refen-al to Idifferent specialties.

Phase two is a re-evaluation.In this phase we can give the Ipatient a final idea of what theymay want. or what they may ultI-mately need. -nus is where webring In computer imaging for asecond time. If you let the patientvisualize how he or she can look.then the patient can feel comfoli- Iable about the fact that you under-stand how they wish to look. Nowis when you Cal1 explain the dilfer-ent modalities of treatment andwhat it will lake to accomplishyour l-esull. We tnfoml the patientthat it may lake three months tocomplete surgery and healing be-fore we can go Into the next phase.It may lake olihodontics or dif-ferent specialties. We lhlnk it isso imporlanl at this poinllo letthe patients kl1OW how they mayeventually look. Now it is a real-ity for lhem, but we give them

Imore than hope -we give themthe pnntout photograph fromour imaging compuler.

Has computer imaging en-hanced treatment acceptanceIn your practice?

Dr. Galber: Computer imag-Ing has created a major boon Inour practice fi"om the slal1dpolnlof treatment acceptance R~nlislspreviously had no way of tellingpatients what it is that we intend-ed to do for them Computer imag.ing makes it all the more tangible.Now patients can see exactly what

be taught that these initial pro-cedures are an integral part ofachieving their true desire. A)-though many patients come intoour office knowing what theywant. many have additionalproblems, or the solution theyenvisioned may not really ad-dress their real concern. It Isnecessary for us to interpret whatthey're telling us, and under-stand their need,

For t'xwnplt' .the teeth may lJeshort and wide, and t'looinl( th('space may only exacertJate tileproblem. They nlay nero a surgi-('al procroure to remove the exces'sive ~um tissue. makin~ tile teethlonl?;er and chmll(inl( l!le silholl-ctte roml rrorn short mld S(luart' 10long and ovoid. If the patient goesU1rough the process of learningfi-orn the book, Change Your Smile,or computer inlagil1g, he or shebegins to w1derstand that closinga gap may not improve the smIle,which is what the patient wanted.Obviously, the patient wollld liketo see the space closed, but he orshe might also ask if there isany-thing else that could be done abouta "gummy" smIle or if we could alsomake the teeth longer and a dIJfer-enl shape.

Before we go any further,ten me more about this excitinghigh-tech piece of equipmentthat I have seen in your office -the voice-activated chartingsystem. What value has itbrought your office?

Dr. Garl>er: Currently. we arcusin~ a uniquc probing system(Victor) thaI allows us to do a com-plete periodontal charting of pa.lirnts This voice.aetivated diag.nostie system allows us 10 deter-mine whether there arc problemswilh Ihe patienl's temporoman-dibular joint, or if there is possibledysfunction due to soft tissueproblems

Vlelor has ensured that all ourpatients havc dcrinilive, preciselydoeumenlcd cxaminalions andlrealment plans. Instcad or wailinglor an auxiliary to write down whalyou.rc charling, or trying to do ilyourself and breaking the sterilitychain by picking up a pencil ortouching Ihe palient's folder, you !ran simply lalk into a microphonc

Ias you go through thc proccss. II

is all recorded and thcn graphical.

ly slored. recorded. and printedoul in a mulli-colored rormat onboth a monitor and on paper. Ithas the ability to describe andrecord the existing restoralions inthe palient's moulh In addilion todelailed examination of theperiodontium and a TMJ exam- in.alion. We have found that less ithan 15 percent of the denlislsin ithe U.S. do a complete charling ofa palient's mouth. When you havethe voice.actlvated system, you oryour hygienist havc the ability tobe Ihorough, unassisled. rapidiy

I and without compromising the

These excerpts from an in-terview with Drs. Goldstein andGarber are reprinted with per-mission of Dentistry Today.

potential end result. or is tile "mp"not worth it -nlere are some pa-tients who have not liked what wehave encouraged. If we had com-pleted therapy. they would havebeen miserable. had we not haathe computer ana stopped In time.

In years gone by, we have toldpatients that they were goIng tolove the treatment. We used totake a study model and photosand tJy to expla!n to them whatthey were goIng to look like, butquite often the patient's percep-tion of what we had said was quitedifferent to what we thought wehad been tellIng them.

We caution you that you can-not rely on computer Imagingalone. It is a wonderful adjunct,but not an excuse to not com-municate effectively with yourpatienl

So, if we rely too much oncomputer imaging, we mIght gooverboard and thenby the pa-tient may expect too much ofthe dentist?

Dr, GoldsteIn: There is noquestion about the fact that wemust be able to deliver what weshow the patieni, even though thecomputer Image is no guarantee ofthe patient's final result. Basically,we are trying to refu,e and definewhat the expectations of patientsare. We are makIng our best effortto extract the patient's idea ofhowhe or she perceives what they aregoIng to look like. This will Im-prove. The computer Imaging oftomorrow will be three-dlmen-sional. We are lackIng that today,but we have come very far fi-omwhere we were when we had noth-Ing. It is almost as if we areemerg-Ing fi-om the -cave man days- InpatlentcomrnlU1lcatlon. HIgh-techha" helped us 10 do that..

By Dr. Hugh F. Doherty, C,

What has been the responseof your patients to the laser?

Dr. Garber: The patiellts arevery excited at the collcept of-star wars" techllolof!Y -theyare all used to the DislleyWorld-type of laser show, The fact thatyou are usilll:( a beam oflil:(ht tocut without actually touchilll:(the tissue is all illcredibly excit -illl:( collcept to them, The bell-efits are that the patiellts seemto have much less post-opera-tive paill alld discomfort,

We touched on the role ofhygiene in the last interview.What about maintaining theseesthetic restorations you aredoing?

Dr. Garber: We have all ill-dividualized regime we tailor roreach patiellt .Our hyl:(iellists areveJy ellthusiastic about the re-sults we are gettillg OIl a Ilewprol:(ram combillilll:( the Rota-dellt plaque removal device withthe Victor Voice chartillg. Thisway patiellts are shown OIl theTV mollitorthespecillcsites tllatare bleedillg areas or illlectiv..areas alld call thell use l\leirsite-specillc Rota-delll, applyingit to one tooth at a time takin~care of that specific area Onrecall we have really seell anellomlous improvement in ourpatiellts' overall home care. Thiscombinatioll of the Victor Voicecharting with the Rola-dellt hasbeell the bac!,bolle or 'ill excellent

I soft tissue maJIagement prol:(J-aIlI

FP

developed byouroWIl hyl(iene It'aJllof Paula Stewm1, Cindy Brooks,l3arlJaJ1\ W'Wler. aJldGail Hcytll'Ulloimprovepatient ('omplu1ru'ewitll Ihome ('are I

Durlngyour ADA video pre-sentation you spoke about the"T-Scan". Tell me first of an,what is it?

Dr. Goldstein: A T -S('Wl "" amylar-typ(' stlip in a holder (,011-tainini( a multilude ofele('trOlli('strain i(aul(es When lh(' patientbites on this, the infol111aliOll istransmilled toa (,Ompuler, whereit is ('ollaled and eval(lal('d ioI(ive a dial(ramm"ti(' represent"lion on " TV mOllitor of th('patienls teeth and O('rlus"l ('on-ta('ts. The innovative ('hanl(e isthaI not OIlly do you rei(istt'ro('('lusal ('Ollta('ls, 1)111 also them"I(!litude of the ('onta('l. and ifdesired. even Ihe lime of thecontact.

Also, you get a printoutthat can be stored in the pa-lient.s chart. Since we are acomputer-driven office. the T-Scan can easily be incor.porated into whateveroperatory you need. withouthaving to have separatemonitors or additionalfrcestanding equipment

HrYW do patients react to it?Dr. Goldstein: One of its

best uses is to let patients see in"third-dimension- exactly howthey are chewing, It is usuallythe first time a patient developsan understanding of how theychew and how important a har-monious occlusion really is.

Is your practice involvedin implants? And where doyou see this modality fittinginto aesthetic dentistry?

Dr. Garber: Yes, we surgi-cally place and restore root formimplants in the office. We haverecently had a new surgical suitebuilt to provide more completeasepsis during our surgical pro-cedures.

I know that bleaching hasbeen an important part ofyour practice for over 30years, What role do you thinkthe FDA will play in changingboth patient and dentist at-titudes toward bleaching?

Dr. Goldstein: In the firstplace. I think the FDA in astrange way may have donesome service to the profession-ifno more than to bring thesubject of bleaching back intothe office, It was getting out ofhand, Drugstores acrossAmerica were carrying all sortsof bleaching kits -making it

seem as if dentists were notnecessary for the technique, orfor patients to even see the dentist belore staJiin~ a treatmenton their own. Some people ~othurt, others spent their hard-earned money lor produ!'ts thateither did not work, orwould notwork on them.

Control ofbleachin~ belon~swith the dentist If the dentistbelieves a patiF.'t should havean in-office or an entire treatment performed throul(h homeor matrix bleachin~, then it isconsidered dentist-monitoredbleachin~, and that's where thedecision makin~and treatmentplanninl( for bleachil1~ belon~s-in the dental office

However, we predict thatmore and more dentists will 1(0back to "jn-office" bleachil1l(.which we found was the best.especially when combined withhome or ma1rix bleachin~.

This combination-bleach-in~ device is an enormous helpto simplify the inoffic!! bleach-in~ procedure, We suggeststarting the patient off withthis treatment and then fol-lowing up with approximatelythree weeks of a one- to tWO-hour home matrix techniqueper day, We then like to moni-tor the patient following this,and, if necessary, supply a sec-ond in-office bleaching treatment, In most cases, this willgive the optimal bleachingtherapy required.

What about the teeth thatare too dark to bleach, oreven if you try and fail atbleaching, what do you tellthe patient?

Dr. Garber: If we tl,ink theteeth are too dark to obtatn anacceptable result throughbleaching, then we advise thepatient to consider laminatin~with porcelain This is more pre-dictable than direct veneerin~with composite resin, asopaquing with the fine ~rain ce-ramics is so much more predicl -able than tryin~ to do i( in com-posite. In the same thickness ofmaterial you can accomplish somuch more in porcelain than incomposite.

Is there anything else you'dlike to add to the various in-struments that will be makingup modern high-tech offices?

Dr. Goldstein: Perhaps (hemost impol-tanl concept is ye( tobe fully discussed, and that isthere are humans operating andmaintaining each of [he me-chanical devices and equipmenl

we've talked aboulThese people are the valu-

abl(' members of our staff. 11takes a ('ommilmenl for not onlythe doctors. but ea(.h and everymember ofour slaff. lo help usobtain our practi(.e I.(oals.

We believe we are lu('kyea(.hday lhat we I.(el up and are abletowork ina hcallh prolessionwcreally love The samc has to betrue with our partners and cverymember ofourslaff. Unless theyhave the same desire and ('om-milmen!, lhcy'll probably bc un-happy in our OmC(', or indeed inour prolession -and would bebetter off elsewhere.

DuringlheyearsI have beenlcaching, I have met some In-credible slaff members Irom allover the world, working for do('-tors who were fortunate lo havesuch dedicated team players. Iquickly learned to appreciate thatjust having them in our profession was lucky for all of us, notto mention all the patients. So,regardless of how "high" or slickthe new technology becomes, itwill never replace the dedicationand skill required by our leammembers. Inslead, it will excitethem and all of us even more.Frankly, tcan'twail !oseewhal'sgoing to come oul of the minds ofthe next generation of brigh!young students!

I predict that high-lcchnology developments willincrease in the next century to!he point that dentistry's im-age will change in our patient'scyes. We will continue tobecomc one of the professionspatients will look lo, not justfor relief of discom!ort. but tohelp orchestra!e their well,being and overall cosmetic

I appearance.The technology aJ1d require-

ments lor such roles will makethe dentists of the futureuniquely prepared to providesuch seIvices. I would love to seelhedaywhen my grandchildren,and especially great -grandchil-dren, become the key providersof lhelr patients. total welfare inways we can only dream oftoday..