Dental Tribune United Kingdom Edition

A n extremely skilled cli- nician with more than 17 years of experience in cosmetic dentistry, Dr Su- shil Koirala says that technol- ogy should work to improve health, never to compromise it. His Minimally Invasive Cosmet- ic Dentistry (MiCD) treatment protocol is based on conscious- ness, nature and evidence- based technology that really respects the patient’s long-term health and needs. Koirala, who is the founder and president of the Nepalese Academy of Cosmetic Dentistry and of the South Asian Academy of Aesthetic Dentistry, combines in his MiCD protocol philosophy and ethics, scientific research, and what can be described as a Vedic Smile or holistic approach to dentistry. Worried about the rapid ad- vance in aesthetic procedures, Koirala began to question if the aim of many dental techniques was to improve health or just to offer the patient a quick makeo- ver, regardless of their long- term consequences. Years of practice led him to develop his guidelines for MiCD, a set of principles that stress early diagnosis, dis- ease intervention, selection of minimally invasive treatment procedures, and use of evidence- based materials, taking into account as well the psycho- logical aspects, ethnic background, and actual health needs of the pa- tient. A Pioneer Paper In a ground-breaking article entitled “Minimally Invasive Cosmetic Dentistry: Concept and Treatment Protocol,” Dr Koirala offered a much needed guide to minimally invasive cosmetic dentistry, a discipline that up to now has been more concerned with appearances than with clinical evidence. The article, published in Cos- metic Dentistry magazine, was translated in many languages and attracted many followers eager to at last have a clini- cal protocol for many dental cosmetic procedures that stressed something that while obvious was not widely fol- lowed - preserving as much nat- ural tissue as possible. The ability to differentiate between what a patient wants and what he or she actually needs is a large ethical ques- tion in cosmetic dentistry. In order to address this issue Koi- rala has developed what he calls a simple self-consciousness pre-treatment test, “whereby I ask myself four simple yet hon- est questions”: • How would I treat my own family members? • Will the treatment plan remain the same regardless of who the patient is? • Am I competent and happy enough to take up the case? • Is the patient happy with the Biological, Financial and Time (BFT) cost estimation of the treatment? Koirala explains that “what a patient wants and what a patient needs are two different things. The needs are the basic treat- ments a dentist can provide. But the wants are of a different variety, like choosing clothes in a store: you choose the colour of the teeth, the texture of the teeth, the shape of the smile.” What is Beauty? Since the definition of beauty is different in each culture, it also affects cosmetic procedures. “For Western-style contem- porary smile aesthetics, beauty is white long teeth and a straight smile, but the same parameters don’t apply in Asia,” he ex- plains. “In fact, Asian patients don’t mind having a little bit of overlapping teeth, which they see as natural. So we cannot use the same formula globally in cosmetic dentistry.” Studies have shown that the dental pulp of Asian patient is generally wider, in comparison with European or American patients, and Koirala points out that “preparations with wide shoulders could be a hazard to the pulps in Asian pa- tients.” Even so, many dental technicians fol- low Western stand- ards for non-West- ern patients with different facial features. Koirala warns that “you need clear consciousness while choosing the right technology for your practice, as technology may not always be health-ori- ented”. As a sample, he thinks that CAD/CAM restoration tech- nology still has to be refined in order to be adopted fully in re- storative dentistry. “CAD/CAM presently demands extension for insertion, strength and aes- thetics,” thus, “we are compro- mising health for technology.” “Clinicians still believe that articulating paper mark gives them ideal force component in occlusal adjustment,” contin- ues Koirala. “The ‘big mark big force, small mark small force’ concept has no scientific evi- dence, but most cosmetic den- tists relay on articulating paper marks to do occlusal force ad- justment. Computerised Occlu- sal Analysis System, which can objectively measure occlusal forces of each tooth with the time sequences of occlusal con- tact, was developed almost 15 years ago. It is hard to under- stand why clinicians neglect sci- entific facts about articulating paper marks and still believe in it for balancing the force com- ponent in smile design. This is why I advocate consciousness in dentistry, because technological information is not enough; you need consciousness to rightly use it for mankind.” This is the background against which Dr Koirala re- volted and led him to de- velop the MiCD t r e a t m e n t p r o t o c o l , which he s u m m a - rises “as b r i n g i n g consciousness, na- ture and technology to- gether”. Rather than inflict- ing one’s own defini- tion of beauty on the pa- tient, the dentist must listen to and understand the personal and cultural desires of the individual undergoing the dental work, he says. Dr Koi- rala strives to preserve the definition of beauty set forth in the cultural tradition of the pa- tient rather than following the status quo of a broad, one-size- fits-all plan. Regarding teeth whitening for instance, Dr Koirala says that while some people may need it, “more often than not the colour- ing of the teeth is a perfect bal- ance designed by nature. The eyes, teeth and skin tone should be in harmony. If the teeth are too white, it may look awkward and unnatural.” Changing the Mindset While the principles of MiCD may seem complicated, the protocol is easy to follow and very practical. The reason is that it doesn’t require chang- ing clinical techniques, but us- ing them in a consciousness way beneficial forboth the pa- tient and the dentist. “We don’t say, ‘Don’t cut the tooth this way’, we say, ‘Cut less,’” explains Dr Koirala. In fact, the MiCD protocol does not reject any contemporary proce- dure, including full crowns or bridges; it just asks the dentist to use their consciousness prop- erly to think if invasive options can be avoided, and to use them only as a last resort. In other words, the only thing a dentist has to do to com- ply with MiCD is to change the priorities for a given procedure, to alter his or her mind-set. The framework of MiCD establishes five golden principles: 1“Sooner the Better” — early exploration of diseases and de- fects to minimise possible inva- sive treatment in future. 2 “Smile Design Wheel” — follow these principles (see image), and respect the psy- chology, health, function and aesthetics of the patient. 3 “Do no Harm” — select What’s good for the patient is good for the dentist Javier M. de Pisón discusses a Vedic Smile approach to dentistry ‘The eyes, teeth and skin tone should be in harmony. If the teeth are too white, it may look awkward and unnatural’ page 28DTà Beautifil Flow, available in different viscosities, enhances the applications of Beautifil II. 27ClinicalMarch 28-April 3, 2011United Kingdom Edition Cover of Koirala’s book in Giomers Indirect Restorative System combining unsurpassed asethetics, the strength of ceramics, as well as the benefits of composites.