W. Johnston 'John' Rowe, Jr., DDS, AAACD

	You are sitting in a lecture, early in your career, seeing amazing restorative dentistry - the implant-supported crown, porcelain restorations or Class IV composite resin shown on the screen blends seamlessly into the surrounding dentition, the tissue architecture and health are ideal and the final smile is drop-dead gorgeous.

	You can barely tell which teeth have been restored and if you hadn’t seen the pre-restorative images firsthand, you might question whether any dentistry had been done at all! You think to yourself, “Those patients have to be thrilled! As a provider, it must feel really good to deliver results that look like that! Might I be capable of providing dentistry to that level?”

	The reality is that anyone with drive and determination can excel in the area of 

. The opportunities and rewards of excelling in cosmetic dentistry range from improving outcomes for patients, to growing networking opportunities, to enriching one’s sense of purpose, to expanding career boundaries. An initial goal of improving skills can open the doors of opportunity in several directions. 

	Early on, the motivation is all about acquiring the skill set to be able to provide excellent cosmetic dentistry: improved knowledge in handling and finishing of composite resin, the nuances of photography and shade communication, the artistry of smile design and so on. But that’s just the start - learning to skillfully manage occlusion, seeking out specialists and partnering with laboratory technicians with similar vision, adding and subtracting soft tissue, replacing missing teeth with implants, developing ovate pontic designs, improving communication skills - the list goes on.

Related article: The top 5 ways cosmetic dentistry can benefit your practice

	It is exciting and invigorating to be a student of the art and science of cosmetic dentistry; there are so many nooks and crannies to explore and master. All disciplines are important for optimizing results, but having the knowledge only gets you so far. One must learn to implement and deliver excellent results. As Thomas Edison said, “The value of an idea comes in the using of it.”

	For many, becoming accredited in the American Academy of Cosmetic Dentistry (

) provides a framework in which improved results must be achieved in order to be successful. Accreditation provides a standard and goal that helps dentists and laboratory technicians achieve a high level of excellence across a broad range of cosmetic solutions. For the authors, accreditation in the AACD was an indispensable part of the journey to becoming a better cosmetic dentist. It is a distinction that patients seeking cosmetic dentistry value and search out - another bonus. 

	With improved knowledge and skill in the area of cosmetic dentistry comes happier patients and more word-of-mouth referrals. Patients are diagnosed more thoroughly when the doctor has learned to appropriately, responsibly and effectively incorporate esthetics with other diagnostic parameters such as functional, biomechanical and periodontal considerations. A comprehensive diagnosis results in more inclusive treatment recommendations and, ultimately, outcomes that are attractive and built to last. The appointment book stays full and the practice is more productive. The confidence of the doctor and the team increases, which in turn increases patients’ comfort levels. 

Related article: How to jump start your cosmetic dentistry practice

	Imagine a patient comes to your office for the first time with a discolored, chipped front tooth, a problem she has been living with since childhood. Her parents could not afford to repair the tooth. She relates how she was made fun of in her youth. As a result, she has deep emotional trauma that she has carried with her for years. She has sought you out because of your reputation and skill in the area of cosmetic dentistry and the fact you are an accredited member of the AACD. She is trusting you to restore her tooth and her smile. You convey confidence when you describe the treatment options and show before and after images of other patients with similar problems and solutions - and the patient feels comfortable moving forward with treatment as a result. When the treatment is complete, words cannot describe how happy the patient feels. You can see it in her face. You know your journey to excel in the area of cosmetic dentistry was all worthwhile. However, the journey really never ends. As dentists, we are constantly striving to give our patients the very best that dentistry has to offer in all disciplines. That’s what we all want for our patients every day.

	Having a passion for cosmetic dentistry introduces you to others who feel similarly. Even though people are at various places in the journey, that doesn’t mean we can’t learn from each other. To study and connect with like-minded people is an amazing treasure. These relationships inspire us, motivate us, and stretch and grow us. At first we are the mentee, soaking in all we can, and then we grow to be the mentor, sharing all we can.

Related article: Outside the box cosmetics for outside the guide results

	The AACD has a powerful and formalized system of mentorship as part of its credentialing program, and it is there for the taking. Other teaching institutions, such as the 

, also strongly promote mentorship. It is wonderful to be around people who are committed to seeing others grow and succeed, doing something purely for the betterment of others and the profession, without expecting anything in return. It is powerful and impactful and the kind of thing that builds enriching, lifelong friendships and fortifies the profession with a nurturing culture to pass along to future generations.  

	How many people can say, “I truly enjoy going into work every day”? Most of us will spend more than 90,000 hours working at our career over the course of our lifetime. That is a lot of time if you don’t find purpose and joy in your chosen profession. If you talk to people who excel in the art and science of cosmetic dentistry, they love what they do! 

	As Steve Jobs said, “The only way to do great work is to love what you do.” But from personal experience, we feel the counter is also true, “The only way to love what you do is to do great work.” There is an inner peace that comes from excelling at your craft, striving to be your personal best. Advanced skill and expertise leads to predictability. Predictability leads to less stress and greater confidence. Having the opportunity to make a positive difference in the lives of our patients, staff members and colleagues provides significant joy and, in turn, enriches our lives.  

Related article: 5 reasons you should do direct veneers

	Have you ever had a patient cry tears of joy when you deliver a case? The emotional connection that today’s patients attach to their appearance and self-image is stronger than you might imagine. Seeing tears in a patient’s eyes as they take the first look at their beautifully crafted new smile in a hand mirror is a humbling experience, for both the dentist and the team. Knowing that you performed the cosmetic and potentially life-changing enhancements that evoked this powerful emotional response is one of the unique rewards of our profession. The hug you receive right after is a strong statement about how much your patients value your expertise.

	Excelling in cosmetic dentistry often creates collateral opportunities. Patients aren’t the only ones who value an esthetic outcome - the profession also takes notice of exceptional results. Opportunities for teaching, publishing, partnering with the industry in product development and leadership tracts all start to present themselves. These various avenues broaden our horizons, expand our relationships and provide additional pathways for personal growth. We may need to grow our speaking or writing skills, further enhance our photographic documentation or improve our leadership training - all good things.

	As the potential for growth and opportunities are limitless, you may find yourself pushing your previously perceived limits to achieve excellence in all areas of your life: professionally, personally, financially, physically and emotionally. The possibilities are endless.

Related article: Protect your patient’s esthetic investment with mouth and night guard options

	Patients are not able to judge the dentistry by many of the criteria with which we judge our dentistry - fit, imperceptible restorative margins, prep design, etc. However, patients do have an opinion about how the restoration looks, whether it be a restoration in the smile zone or in the posterior aspect of the mouth. For many patients, all dentistry is cosmetic and appearance becomes a key element upon which the dentistry is judged and we as the providers are critiqued.

	Excelling in the area of cosmetic dentistry can open up a number of opportunities, personally and professionally. It starts with enhancing knowledge and skills in the area of cosmetic dentistry. What’s holding you back from your cosmetic dental journey? 

Articles

Cosmetic dentistry can have a positive impact on everyone, from you to your patients.

4 ways cosmetic dentistry opens doors to new opportunities

	While there have been improvements in caries incidence and prevalence in the United States, caries is still pandemic. By the age of 40, 90 percent of U.S. adults have experienced coronal caries, and root decay affects approximately one-third of adults over the age of 59. It has been estimated that the prevalence of caries among adolescents is 68 percent, and caries affects the primary dentition in 41 percent of young children.

	All age groups and segments of the population are known to be susceptible to developing dental caries. Not all caries 

lesions progress to cavitation, but knowledge regarding the progression pattern of caries lesions is limited. The 

International Caries Detection and Assessment System

 (ICDAS) concept was developed under the direction of Professor Nigel Pitts of Kings College in London, to evaluate dental carious lesions. The ICDAS concept entails the use of a standardized system, based on visual evaluation and best available evidence, to acquire information about early and later stage caries severity. This information is to be used to assist with appropriate diagnosis, prognosis and clinical management of dental caries at both the individual and public health levels.

	The following outlines the treatment steps involved in successfully halting the progression of caries lesions through the establishment of a resin diffusion barrier within the demineralized enamel. Once in place, the Icon resin hardens within the enamel making the site less susceptible to cavitation, and produces an area that is more resistant to continued acid attack. These benefits are achieved without the removal of any tooth structure, either healthy or demineralized. All tooth structure is preserved through the resin infiltration technique.

Related article: Moving caries detection and patient engagement into the 21st century

	The patient, a 34-year-old white male is in good overall health. He attends routine six-month recall visits for dental prophylaxis but admits he isn’t a regular user of dental floss. He presented with an incipient lesion on the distal of tooth #5. Being an excellent candidate for resin infiltration, the patient opted for this treatment after a brief explanatory discussion.  

 is an innovative product for the micro-invasive treatment of dental lesions in proximal regions and on smooth surfaces and available in two variations: Proximal and Smooth Surface applications. Icon Proximal is a specially developed hard tissue preserving treatment for incipient proximal dental lesions. 

Related: Patients 'cried tears of joy' after DMG America's Icon treatment

	Step 1-Cleaning the surface of the tooth to be treated. Before the start of treatment, clean the affected tooth and adjacent teeth. Remove any cleaning residue with water spray. Create a sufficiently dry working field. You should take appropriate measures such as rubber dam, liquid dam or similar to protect the gingival tissue (Fig. 2).

	Step 2-Isolation of the treatment site. Along with 

offers a fast and convenient means for isolating a single proximal area while helping to maintain a dry field. Here the device is placed with the aid of dental floss, allowing quick placement into the proximal area (Fig. 3).

	Step 3-Accessing the sub-surface pore structure of the lesion. To ensure a successful treatment, a proximal separation of approximately 50 microns is required. Introduce one of the enclosed dental wedges into the treatment site. Apply an ample amount of Icon-Etch onto the lesion site (One and a half to two turns of the shaft). Let Icon-Etch set for two minutes. The etching gel will be activated by slightly moving the applicator. Remove excess material (Fig. 4).

Related article: Study finds secondhand smoke exposure linked to increased dental decay in children

	Clinically important: The Icon Etch is a 15 percent HCl solution requiring the protection of gingival tissues. The Icon Etch dissolves a thin layer of remineralized enamel which covers the demineralized tissue. This demineralized area contains porous enamel filled with an air-fluid solution which must be uncovered and dissecated allowing the Icon resin to flow into the lesion.

	Remove the application tip from the proximal area. Suction off Icon-Etch and rinse with water for a minimum of 30 seconds (Fig. 5).

	Step 4-Chemical drying of the lesion. Drying the interior of the lesion is critical if infiltration is to take place. The Icon resin can’t displace any fluid which may be occupying the pore volume of the lesion, therefore desiccation is necessary. Desiccating the lesion’s pore system is accomplished in two steps: air drying and the use of a chemical drying agent-Icon Dry. Icon Dry is an alcohol based drying agent. No moisture can remain within the pore system of the lesion. Any moisture remaining within the lesion will prohibit the infiltration of the Icon resin. Remember, the capillary action of the Icon resin is only possible if the lesion is completed dissecated (Fig. 6).

	Air evaporation is employed to thoroughly evaporate the Icon Dry after 30 seconds. Apply sufficient quantities of moisture free air for 30 seconds. The drying process is employed to not only desiccate the tooth surface, but also the porosity within the lesion itself (Fig. 7).

	Step 5-First infiltration step. Screw a new Proximal-Tip onto the Icon-Infiltrant syringe, and introduce the application tip into the treatment site. Be sure to align the green side of the Proximal-Tip with the area to be treated. Slowly turn the syringe handle until the Icon resin emerges from the buccal/ lingual areas. There is no need to use an excessive amount of the Icon resin (Fig. 8).

A dental hygienist's perspective: Fighting caries with customized care

	Throughout the three-minute infiltration period it is necessary to add small increments of the Icon resin in order to ensure that enough resin is available to fill the entire pore volume of the incipient lesion. Failure to do so will possibly lead to an unsuccessful outcome. Do not apply Icon-Infiltrant under direct operating light as this may cause the material to set prematurely. 

	After three minutes remove the applicator and clear any excess material from the site using dental floss or tape (Fig. 9).

	Step 6-Light-curing the Icon Resin. Be sure to light-cure Icon-Infiltrant from all sides for at least 40 seconds (total). It is prudent to cure for the entire 40 seconds to ensure the complete curing of the Icon though several millimeters of tooth structure. A leading cause of failure, when using Icon, is the failure to allow the different materials the necessary time to perform their duties. Therefore, instructions should be followed to the letter and on the clock (Fig. 10).

	Second infiltration step is undertaken utilizing the same steps as in the first infiltration step. Screw a new Proximal-Tip onto the Icon-Infiltrant syringe, repeat the application as before and allow the Icon resin to penetrate for one full minute (Fig. 11).

	Removal of excess resin. After one minute remove the applicator and clear any excess material from the site using dental floss or tape (Fig. 12).

A dental case study showing techniques for treating a proximal caries lesion.