Managing Patient Expectations – What We Can Learn from Facial Aesthetics – PDP180

Managing patient expectations in Dentistry – there are some MAJOR lessons we can learn from facial aesthetics practitioners.

We’re diving into a conversation with Dr. Katherine Bell that’s really going to open your eyes about communication. Despite beauty being subjective, we find a lot of similarities in how we talk to and get consent from patients, whether it’s for facial aesthetics or dental procedures 

So, even if facial aesthetics isn’t your cup of tea, think of this episode as a deep dive into communication and consent. Plus, it’s Documentation Month on Protrusive Podcast, and this episode is just the beginning!

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Protrusive Dental Pearl: Tailoring consent to each patient involves discussing only the risks that matter to them, using standard forms for GUIDANCE, not for completeness. It’s about clearly explaining how we’ll minimize these risks, ensuring the patient feels secure and informed about the precautions taken. For example ‘Mrs Smith, your tooth is very badly broken down and this can be a very tricky extraction. The way we are going to make it easier is by carefully dividing the tooth in to 3 roots’

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

  • 01:36 Protrusive Dental Pearl
  • 03:33 Dr. Kathryn Bell Introduction
  • 05:01 Dr. Kathryn Bell’s Journey in Facial Aesthetics
  • 09:08 Perception of Facial Aesthetics 
  • 15:34 Discussion on Documentation and Patient Education 
  • 20:05 Patient Consent and Managing Risks
  • 25:13 Screening for Body Dysmorphia
  • 33:50 Considerations for Patients with Depression Seeking Aesthetic Treatments
  • 38:06 Learn More with Dr. Kathryn Bell

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If you loved this episode, be sure to watch Botox for TMD – Indications and Protocols

Click below for full episode transcript:

Episode Teaser: So red flag number one was that she walked in and you could clearly see that she'd had quite a lot of work done already. So it wasn't subtle changes. It was this lady has had treatment before and her history was that she had been to a number of other practitioners and she wasn't happy. So massive red flag right there.

Okay. So she’s seen lots of people, she’s had lots of treatment and she’s still not happy. Okay. And the second one, like I said to you earlier, is I often give my patients a mirror and then get them to kind of point out what their concerns are.

Let me guess, her mirror was touching her nose.

Oh, no, no, no, Jaz. She had her own mirror. It was a magnification mirror.

Jaz’s Introduction:
Oh my goodness. Protruserati, I know what you’re thinking. Jaz is doing an episode about facial aesthetics? Is everything feeling okay? Everything is just fine, guys. Trust me on this one. This episode with Dr. Katherine Bell, one of our own Patruserati, is going to blow your mind when it comes to communication.

There’s so many parallels we can draw from when you’re consenting patients to something that’s so, like, subjective. Like, beauty is in the eye of the beholder. And that worries me about facial aesthetics. But actually there’s so many parallels we can draw between communicating with our patients and consenting our patients for facial aesthetics and general restorative dentistry, especially like aesthetic dentistry, edge bonding, veneers.

There were so many parallels. So even if like me, you have zero interest in facial aesthetics, think of this like a communication and consent episode, because this March 2024 is documentation month. So this is the first of our many episodes on documentation. Remember that later this month, I’ll be covering about which software I’m using currently to auto create my notes. So it’s listening to my notes, listening to my voice and transcribing and using AI to write your notes for me so that my wish of never having to write notes ever again is almost there.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. As you know, every episode, I give you a Protrusive Dental Pearl. And let me be honest with you, Protruserati, I’m actually losing track of all the pearls. And my biggest fear now is repeating the pearls. And when I come on the spot to record these intro and outros, often at random times throughout the day and night, I kind of stall at the Protrusive Dental Pearl. I’m going to start a new thing.

I’m going to get our guests to help us with the Protrusive Dental Pearl. So today’s pearl is brought to you by our guest, Dr. Katherine Bell. Let’s hear it from her. Katherine, what is the Protrusive Dental Pearl for today?

[Katherine] Dental Pearl
So my Dental Pearl is all about consent and making consent personal to the patient in front of you. So we often have standardized consent forms or like things that we say to our patients, but it is one making sure that only the relevant risks are discussed with the patient, but also absolutely key is discussing how you’re going to reduce those risks for that patient. So making sure that they know that in your hands, they feel safe to go down this procedure and that the risks are going to be minimal because you’re doing X, Y, and Z.

And to follow on from that, it’s exactly how you say later in the main interview, when people will listen, is that by actually mentioning these factors, these extra things that you’ve learned to mitigate their risk, it’s stuff that you’re already, we’re all doing, we’re all doing these things already.

But if the patient doesn’t know you’re doing them, then their perception has changed. So it’s actually, this is a communication skill element that you’re letting the patient know that you’re going to approach it in a certain way to minimize this risk and that risk. But sometimes we do that anyway, but we never verbalize it to our patients. So it’s an opportunity, consent is an opportunity to show yourself off as a fantastic communicator and to really instill and maintain that level of trust that the patient has in you, I think.

Absolutely. It’s gaining their confidence. It’s like, okay, so this could happen, but my practitioner is doing this and I feel safe about that.

It’s a missed opportunity otherwise because we’re saying all these bad things that can happen but also it’s an opportunity for us to show how fantastic we are and how much care we take to mitigate those. So this is probably one of my favorite pearls. Thank you so much.

Ah, thank you.

Thank you, Katherine, for that Pearl. Let’s now join the main episode. Oh, and make sure you make it to the end. And join me for the outro to make sure you don’t miss any of the juicy bits.

Main Episode:
Dr. Katherine Bell, fellow Protruserati, it’s always, always nice speech to Protruserati, but especially you, I’ve been, I feel like I know you so well, just from the connections on the live that we have and recently, in Shelton. Yeah, I think that was the first time we met, but it didn’t feel like the first time. Welcome to podcast. How are you?

I’m great. Thank you so much for inviting me on the podcast today. I’m really, really excited to chat with you. And yeah, it was lovely, lovely, lovely to meet you in person for the first time, had the same experience, felt like we already know each other and we’ve known each other for a long time. And you know, I love that. I love that relationship. It’s great.

And it’s been great to, you know, talk about all sorts of things over Instagram and stuff, as well as the geeky, you’re on Splint course stuff, so the Geeky education, the occlusion stuff, and that’s been fun. But sometimes the parenting tips that you might give or recommending a book that you have in the past, I’ve always really appreciated that. So please tell us about Dr. Katherine Bell, the mum, the dentist, the individual, the facial aesthetics practitioner, all those things.

Sure. So I am a dentist, obviously. I qualified in 2005 from Leeds. So that’s a scarily long time much longer than I care to admit. I have two kids. I have four stepkids. My husband is a retired rugby player.

He’s now a mortgage advisor. So that’s a little bit about all of me. I started doing facial aesthetics in around about 2015, so quite a while now, and kind of started doing that in a clinic in Bristol, and then kind of grew that aspect, did much further, more advanced training, and just found that I have a real passion for it. And so that is an area of my kind of practice that I’ve been growing ever since then.

And I asked you a question, right, when I met you in Cheltenham, like what percentage of your clinical work is facial aesthetics. And do you still enjoy the deep in subgingival caries matrix in that kind of stuff?

Yeah, absolutely. I wouldn’t want to give up either sides of my practice because I love the intricacies of dental work. But then a lot of the skills that are needed for dentistry are transferable to facial aesthetics. And that’s why they they blend so nicely together. But I do, I have a lovely mix of facial aesthetics and dentistry. And I just, I wouldn’t want to change that at all. I love having both. I think I get bored very quickly if I didn’t have either of them. So I love that variety.

Well, on the topic of today’s conversation, you don’t look like you’ve been practicing for 20 years. Right, coming up to 20 years next year, right? But the reason I highlight that, Katherine, is because you got introduced to facial aesthetics 10 years as a dental school and 10 years is a good amount of time where you’ve really got the foundations and some people get into maybe one or two years out of dental school and some people may wait 15, 20 years to begin their implant journey even. So we’re all on a journey and it’s all about constant learning, which I know you are a lifelong learner It’s super super clear to me.

What advice would you have to someone who’s considering facial aesthetics? Do you think they should do what you did and purposely choose to wait 10 years? Or is that just the way it worked out with family with you and perhaps you wish you did it sooner? Where do you lie on that?

So, it purely came up as an opportunity. It’s something that I’d been thinking about doing for probably about five years prior to having the opportunity to do the training. But the practice that I was working at the time. It didn’t really fit in with that and I wasn’t keen on kind of opening or starting a side project alongside the dentistry.

I was working in a predominantly NHS practice at the time and the area that I was working in kind of location wise, again, it wasn’t really a good fit. The other thing is obviously, even in the time between me first thinking about it and then doing the training, facial aesthetics.

The dentistry wasn’t a massive thing at the time. And so that was something that started taking off and I was able to kind of join that journey at a time that was appropriate for me. I was actually given the initial training with Dr. Brian Franks, who’s also a dentist. And that was provided for me by the clinic that I was working at because they were so keen on growing that area of the practice.

So I was exceptionally lucky to have that opportunity. I’d like to say I’ve been exploring it for a while and I probably would have started doing it. Anyway, I just had that amazing opportunity at the time to kind of go down that route. Yeah.

I really admire your answer and I really admire you and your mindset. And I want to just distill that again and dilute it and repeat it again for everyone to not dilute. I want to concentrate into it actually for everyone listening, watching, because in case anyone was multitasking, what Katherine said was that she identified that the environment that she was in would not have benefited from this additional new skill set.

And so what I want to highlight is no matter what skill it is, like if you want to go on a denture course, or you want to go on implant course, you want to go on whatever, if it’s not going to be truly serving your population, if you’re not going to be able to implement it in whichever environment you’re in, like put this way, if you are in a public health practice setting in the world, and maybe 40, 50 percent of what you’re doing is extractions and dentures.

Then you know what? You go on that oral surgery course and you go on that denture course because you know what, you’re going to get to apply it straight away. Maybe that’s not the point for you to consider your facial aesthetics course. And I think you recognize that and I think you waited for the right time.

And I just want to really highlight that as a way to think about your education and planning your courses, which is a regular topic that comes up. Now, I mean, this episode is a reflection of me in a way that the episodes tend to go with my interests. Right? Like occlusion comes up so often and stuff. The reason I’ve never, I mean, we talked about Botox with Sheila Lee, but again, we niche it down to masseters and stuff for bruxism.

So the reason I haven’t really got into it is because this is not my space at all. This is not an area that I have any interest in and I made peace in that. But what I really want to get from you, Katherine, is the whole setting expectations, because I guess one of the reasons where perhaps I would have a barrier to getting into facial aesthetics because I totally, you already made a point that actually for dentistry, nowadays the pathways are much more established than they were back when you got started.

And it’s an injectable and we are always using, you know, L. A. where we’re good at injectables. So it goes hand in hand in that, but it’s the whole concept of beauty is in the eye of the beholder. And sometimes I see these before and after images. And Katherine, I kid you not, they look like the same to me.

I can’t see it, but this is me. I haven’t, I don’t see it because look at me, right? It’s not my space, right? So, look at you, you have like no wrinkles, you look amazing kind of thing. So we’re different in our values in that regard, right? So, and that’s how you’ve got to do things that are in tune with your values.

So for me, it was like, how can I get into this space when I don’t even value it myself? So I guess the question I’m trying to ask is, beauty is an eye in the beholder. Is this something, do you think you’ve always been attracted to the beauty? Is beauty one of your core values?

Oh, that’s an amazing question. I love that. So, is beauty a core value? Probably not. So, my whole ethos around about facial aesthetics is kind of aging on your terms. So, I fully support people who don’t want to go down the route of aesthetics. If they want to age naturally, and maybe would just want something like a better skincare regime, or even just promoting skin health.

Brilliant. Amazing. I fully support that. Go you. That is brilliant. Other people might come in and say like, oh, I’m just looking a little bit tired. I don’t like the fact that I’m looking haggard. These are words I hear a lot, tired, haggard, angry, sagging. These are the words that people often bring into their consultation.

And so often it’s just helping people come to terms with the aging process on a scale that is appropriate for them. So with regards to the kind of beauties in the eye of the beholder. Absolutely. But again, as dentists, we have these ideals for beautiful teeth the golden proportion, the golden ratio.

These are all mindsets that we have, and we are constantly looking at beauty as dentists. And again, it’s kind of just expanding that into the face. So I’m looking at teeth and I’m looking at the whole face and there are kind of similar things with a facial proportions that align with kind of dental aesthetics and just bringing everything in alignment with kind of bringing people closer to the ideals of beauty rather than further away.

Because obviously the other thing is you see the facial aesthetics treatments that you notice are often the ones that have maybe gone a little bit too far. So, the big kind of trout hat lips and really kind of stretched tight skin that just doesn’t look natural. It’s taking people away from the ideals of beauty.

And so for me, it’s really important. And I regularly do it. Saying no, knowing when to say no, and not actually just going along with what the patient feels. They need and that again one of the questions-

Because we’re still practitioners and we still have to respect that element. Yeah.

Yeah, absolutely. So often it’s not something major and like you say it can be very, very subtle. But then so can some of the dentistry that we do even with things like-

A little bit of edge bonding, which a lot of the lay person like they might go to a spouse and show them the edge bonding, like your teeth look the same, but to the patient, it means so much. And to us as dentists, we’re taking like these zoomed up photos and we’re getting very excited. So what I realized when I was writing this question that, I know that Katherine’s going to say this, but what I really want to highlight because it’s so true, right? Because when we’re doing aesthetic dentistry, which we all are, right?

We’re not going to do do a central incisor class four and make it a blue shade with a funny shape we’re doing, we’re all practicing aesthetic dentistry all the time and I love how you said that expands. But the whole aging on your terms I love that. I know I was expecting you to say that you know what yeah beauty is a high value of mine kind of thing but I love what you said about respecting the patient like my wife’s been on my case right to dye my beard like my beard is really graying like really fast and my wife and my mom and all the important people in my life they’re on my case ‘Jaz you must dye.’ Now personally, I’m like you know what? I like it. I don’t mind it.

Okay. And so I’m cool with it. Some patients were seeking this reducing aging, just like you said, aging on that terms and you’re able to offer a service for them. I actually really liked that. But I think the true intricacy of this comes out when I know the dimensions of teeth inside out.

I know the anatomy of teeth inside out, but I seldom think about the nasolabial fold. I never think about the eyes and stuff like that. But when you actually start looking at the face and studying what norms should look like, that then trains your eye. I guess that’s where the education comes in, right?

A hundred percent. I mean, also the other kind of link with what I do is I have done orthodontics training and that does train your eye for looking at things like the facial profile, facial proportions. And again, so that massively comes into it. So, you’re looking at maybe a retrographic mandible.

Are you going to correct that with surgery or are you going to improve it with placing careful application of fillers, for example, which can be done. I’ve had that done myself cause I’m quite class two. I’ve had some treatments, my chin, just to bring that forward slightly. And so that’s just made my profile, in my opinion, just closer to that ideal proportion.

Me too, by the way. My beard, my voluptuous beard is actually making me more class one, maybe to class three. Like I’m actually really retro. Nothing mandible. So literally I see what you mean in that regard. it’s a weird way of thinking about it, but I totally see what you mean there.

Yeah. But you’re right about the whole appreciating faces. When I did my ortho diploma. I really started to look at everyone in a different way in terms of faces. So, but I’m still very much at the macro level. You’re about the skin health as well. I think it makes it easier for you to train your eye. The more you get exposed to that when you go on the courses to learn about it.

And I guess those subtle changes. that I see them and I don’t see that change. I’m kind of like the lay person who’s looking at the edge bonding and saying, I don’t see the difference. So it’s kind of at that level. And the more you train your eye, but the difference you get to make to a patient, like that edge bonding to that individual makes a huge difference when I speak to them.

And when you allow them to age on their terms, again, beautiful, it makes a huge difference to them. So fine, that’s really helpful for me to understand. And let’s talk about managing expectation. Now it is March. It is going to be documentation month for the themes that we’re covering on the podcast.

So obviously, I mean, just tell us about the protocol that you do, for example, from photos to, I don’t know, do you do draw any maps of their face and like highlight things? Or do you get their, a photo of them and iPad and start labeling? How does documentation work in your space? And remember, I’m not in your space. I have zero idea. You please tell us exactly what you do.


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The best way to make an account is on your web browser. Head to protrusive. app and then you can use the login credentials you made on Android and iOS. What we really want to do is to harness the power of the protrusive community and create a platform you can share and grow together. And you know what?

It’s way better than Facebook. So if you haven’t already, check it out. Just do bear in mind that we manually approve every single application. So it might be a little bit slow to approve you. But we only want dental professionals on this network to keep it a safe place and so that we can share failures together. Head over to www. protrusive. app to know more.

I mean my consultation always starts with looking at kind of where the patient’s concerns are and what they want to address. And I develop a fully comprehensive treatment plan just as I would do for dentistry. So I’m looking at skin health.

I’m looking at whether a little bit of toxin is going to benefit them. Is that going to align with their ideals? Because it isn’t for everybody. Not everybody loves it. And then looking at other treatments, whether it’s just kind of skin boosters, microneedling, or going down the routes of kind of volume restoration, which is where the fillers kind of come in.

So it is being very comprehensive. So, and again, in that I will often give my patients a mirror and I’ll say to them, okay, I want you to pinpoint exactly what your concerns are in that mirror. And I will document that down. So patient locating this area and these are the words that they use.

It’s all in the patient’s words, their concerns, which is really important. And at the end, I have got, I’ve got a picture in my head I can already, is that thing a beginning with the end in mind? I can see where treatment can be placed. I can map that out in my mind. I have these little face maps on paper and I will often use that to show the patient.

It’s like, this is where I’m going to do this and this and this, and this will be what that does. So I’m explaining the procedures that would get them closer to their perceived ideal. And also the other thing is I will say to them, we can do this in a gradual approach because it’s really important to get used to small changes first.

I don’t want to change you. I don’t want to stop you from looking like you. I just want you to look like you on the best day when you’ve had eight hours sleep, eight glasses of water, all of those things. So them on their best day. That’s what I’m aiming for. I want it to be subtle. I don’t want them to walk down the street and people go, Oh my God, look at how much work they’ve had done.

So this is all, again, part. And I say to my patients, I would rather do less. I’d rather undertreat because it’s much easier to add more at a later date than remove things at a later date. So if we need to add more, fine, we can do that. But I don’t want to add too much to begin with. So getting used to small changes is a big deal.

So for example, somebody who comes in with very, very thin lips, I’ll say, let’s get you used to having some lips and then we can build on that. So we’ll get you and the people around you used to having some lips and then we might get them used to having a little bit more, but it’s much better. It’s a marathon, not a sprint.

It’s not kind of all in one go. I’d much rather take it just, and I explain that to my patients. I have, and I give details about the actual procedure, is it going to hurt, what I can do to manage their discomfort, what the expected risks are, what the expected kind of side effects are, so that they’re fully informed about what the whole procedure involves. And yes, I absolutely take photos so that I’ve got a baseline and then I can compare those to the treatment results.

Because that makes it objective because their subjective opinion on what their facial feature is like, and you’re going to improve it. But then by taking a photo before and after, it becomes more objective.

Now we’ll talk about later about body dysmorphia and patients changing their mind. And that could happen even with veneers and stuff. We’ve talked about that before. My mind was racing. Wow. When you were talking about all that, that was amazing because I’m constantly drawing back to my experience of that consultation where I show in the mirror, but this time it’s not about their face, it’s very much within the frames or the border within the lips, which is the teeth.

And so I’m making a problem list or everything they don’t like. I don’t like this gap. I don’t like this. I don’t like that. And I’m making a list. So exactly the same as what you do in the facial aesthetics realm, just with a broader scope, and then you know how you do a mock up and then you find that patients who’ve got worn teeth, they always say, Oh my God, my teeth are too long, but it’s because they’re not used to it.

And then you can sort of modify the wax up and do this. So again, similar thing. And, but whereas with the mock up stage, you can still make changes. With you, you’re just going gradually and going at the patient’s pace and they’ve consented for it. So I like that. And you’ve already covered photos. In terms of consenting, just in terms of documentation, is it a traditional consent form that you run through and how do you personalize it to the patient?

So every consent form has an area where it says what the areas that are going to be treated and the products that are going to be used. So that’s kind of how it’s personalized. Now, in general, the kind of, I will go through, so there’s certain risks on there and I’ll say, well, this risk doesn’t apply to you.

This one does. And I’ll go through that. And also the other thing that I’ll talk about is how I mitigate a lot of the risks. So for example, one of the biggest concerns in fillers is a vascular occlusion because that can be massive, have massive detrimental effects on a patient. And I say to people, you know, I am extensively trained.

Sorry, this is when fillers go into a blood vessel? Is that what it is?

And it can cause necrosis of the skin, which is then obviously a plastic surgery job. So it’s a big deal. It’s a big deal. But there are things that can be done to mitigate that risk, reduce that risk to as low as possible. One is an extensive understanding of anatomy, like visualize, whenever I’m injecting, I’m visualizing where the blood vessels are.

I’ve got that mental map in my head and injecting very, very slowly. So any time, so if a patient experiences sudden pain and very intense pain, then that is a sign that you’re in a blood vessel, but doing it very, very slowly as well as a big deal. And so the other thing is I have a device called a target call, and what that does is it rapidly calls the area where you’re injecting, so that causes vasoconstriction, so obviously with the blood vessels being smaller, you’re less likely to hit them, and also it makes it very, very comfortable for the patients during the procedure.

And then I also explain, I have hyaluronidase, which is an enzyme that breaks down the hyaluronic acid. So if I have any concern at all, I will immediately inject that, and we’ll retreat at a later date because it is not worth having that potential risk happening. And that’s assessing. So I’m always assessing like the capillary refill time.

Anytime that I place any fillers because if that’s sluggish, then there’s a potential risk for having either obstructed or compressed a blood vessel, neither of which you want. So it’s understanding the risks and how to reduce those risks as much as possible. And I know a number of practitioners who have trained in fillers, and then they’ve been so scared about these risks.

That they then haven’t gone on to treat people and kind of build the experience. And I can completely understand that because it’s quite a scary thing. But then all treatments have risks and we’re dealing with treatments that have risks all the time. And again, I think it is just explaining to people how we are going to manage those risks.

So what I was thinking of when you were saying all that was ID blocks. Like if you actually look at the pterygoid plexus and all that stuff, even an ID block is actually a very funky area of the mouth when you actually really strip back and look at the blood vessels and the skeleton. But because we have our sound and standing, we’ve practiced and we know our landmarks, that’s how you stay safe.

Now, if you go really wayward, yes, you can go to pterygoid plexus and all those hematomas, et cetera, et cetera. But just to give people some confidence that if you are thinking with, don’t be driven by the fear, be driven by the pursuit of knowledge and learning anatomy really well, which is the real secret of everything here, isn’t it?

Learning anatomy foundationally. The other thing that I was thinking of is drawing comparisons to general dentistry. As you were saying, I love when I’m consenting patients in general as part of talking about documentation. I also cross out bits of the form which aren’t relevant for them. I’m not the biggest fan of consent forms.

Some of that facial aesthetics, I think it makes a lot of sense for wisdom teeth. For me, I do. But generally for general extractions, I just really go through with them. I do lots of audio recording, which we’ll talk about another time. But one thing I do is just like you, I say, well, look at this big filling in front and behind.

There’s a chance that these could dislodge, right? But here’s what I’m going to do to mitigate it. I’m going to section the tooth so that it puts less forces. This is why you might hear drilling. So again, you’re going over the issues, but you’re also talking about how to mitigate them. And that is a real communication pearl right there.

Talk. I don’t think we do that enough. Like sometimes we might say. X, Y and Z can happen, please sign here, but actually it really shows your skill, expertise and high level of understanding when you actually tell them, you share with them the good stuff you do anyway to mitigate it.

Definitely. And you’re absolutely right. Kind of. These are all things that we do as dentists. And so it’s just kind of transferring those skills into another area of practice. So I really, really think that dentists have this amazing skill base to transverse facial aesthetics, I genuinely believe that dentists are the best facial aesthetics providers, might be a smidgen biased, but, and it’s because we’re so used to working.

Like you say, we do injections in the face all the time. We understand the anatomy and then all the kind of skills around consent and managing expectations that we do every single day can just be transferred across to a different area of practice.

Okay, well, talking of transferring skills across patients who change their mind about cosmetic treatment now, we have covered in a few episodes before, including with a recent one with Daniel Cattell and Neel Jaiswal about patient having veneers and then the boyfriend makes a comment and then they suddenly feel upset and how to manage that.

Have you experienced anything like this where you do some sort of fillers or toxin and the patient comes back? Well, I mean, I guess the toxins, it’s the beautiful thing about is it goes back is reversible in a way that naturally with time, three to four months later, there’s a degree of relapse to the baseline, which is great.

But any experiences of managing patients who you suspect body dysmorphia where no matter what you do, they’ll always be looking at very critically and they’ll never be happy. How do you screen for that?

Oh, that’s a really tricky one because it’s not something you can just say, turn around and say. Do you have body dysmorphia, but can we come across this in dentistry? I think it is much more subtle in dentistry. And actually I don’t think we’re very good at picking it up in dentistry. And I can think of a number of examples where I’ve come across it in dentistry, probably more so than I have in facial aesthetics, but there are two patients that I’ve treated that come to mind with regards to kind of body dysmorphia.

So one was a lady who came for the consultation and it’s picking up on subtle red flags. So red flag number one was that she walked in and you could clearly see that she’d had quite a lot of work done already. So it wasn’t subtle changes. It was this lady has had treatment before and her history was that she had been to a number of other practitioners and she wasn’t happy.

So massive red flag right there. Okay. So she’s seen lots of people, she’s had lots of treatment and she’s still not happy. And the second one, like I said to you earlier, is I often give my patients a mirror and then get them to kind of point out what their concerns are.

Let me guess. Her mirror was touching her nose.

Oh, no, no, no, Jaz. She had her own mirror. It was a magnification mirror. And it was-

Oh my goodness.

Yes, exactly. So body dysmorphia is like an obsession with perceived imperfections and it is an obsession. So these people will spend hours scrutinizing themselves and that the issues that they perceive are huge in their heads, these are big things to the point where people may not leave the house.

They might avoid social functions, and there is a huge crossover with psychological problems. So depression illness, OCD in particular, OCD is a big one. And again, you’re not going to turn around to a patient and say, do you have any psychological problems? But again, the medical history can be a sign, if they’re on a certain medication.

Or you can pick up little, little, subtle things like that where it all fits together into a big picture. And again, it’s kind of broaching that subject very, very carefully with people. And for this lady, I just said, look, I don’t think I’m the right person to help you with these concerns.

I said, I don’t feel that treatments I offer will manage your expectations. They’re not going to meet your expectations. And I can’t remember how I said, but I could have very, very carefully worded it and directed her. To see her GP, just to assess whether there was some other underlying psychological problem that was maybe affecting the perception of these, but it was very, very carefully worded.

So as not to cause offense but just kind of gently suggesting that maybe that there’s another thing that needs to be addressed. Now, the other thing with body dysmorphia is, is as well, and again, this isn’t something that you can really bring up in a consultation, but there is a big crossover with sexual abuse.

So a history of sexual abuse is often a trigger for body dysmorphia. And it’s not everybody, but there is quite a high correlation between the two. So with body dysmorphia, there’s a psychological concern there. And it’s that that needs addressing. The other lady that springs to mind was somebody who came for a consultation and during the consultation, she was really distressed, like very, very upset, crying, saying, it’s affecting her so much that she doesn’t go out anymore, that she doesn’t see any point in living.

And it was that point where I was like, okay. I need to speak to your GP about this. I said, I really think that you need some help immediately. And she goes, I’ve been trying. I’ve been trying. And I know I’m so anxious. I’m so depressed. And I was like, well, are you happy for me to phone your GP?

And she was like, yeah, please, please do. I hate feeling like this. So I did, I phoned her GP and I said, look, you need to contact her today. She’s in mental health crisis and I’m very concerned about her. And they would then, and to be fair, they took it on board and I know that they were going to contact her that day.

And I don’t know what happened after that, but I feel that for her, that was the absolute right thing to do. I also refunded her consultation fee because I was just like this poor lady. She’s just in such a bad state at the moment. So they’re the kind of two that really spring to mind when it comes to-

And the first patient, did you also send her on her way? Because there was all those red flags, but did you also refund her as well?

Yeah, oh, absolutely, absolutely, anything like that.

I was just going to say, it’s a good practice to do that. If you can’t help someone, like, you know what, take your money, it goes well, because I think you’ll be served better. And it’s important to do that, just, it’s not going to make a massive dent in your life, and it’s a good thing to do. I just love everything you said that Katherine, because it just shows your values. It shows that you truly are a nice and I can vouch that you are super geeky and you are a total Protruserati.

It’s been, yeah. And it’s been great to see you on Protrusive Guidance recently as well. How are you finding the app? It’s a bit different. It’s been better than the previous one.

Yeah. Really loving it. Really easy to navigate lots of support amongst the Protruserati and obviously with yourself as well. Just, I love it. It’s great. Yeah. I’d say it’s the new Facebook for dentists.

That’s it. So Facebook is crap. We know that, it is all about Protrusive Guidance and if you are, reach out and learn and message, Katherine as well as your Instagram. You can DM her on Messenger, on Protrusive guidance. So what is your Instagram?

So it’s @drkathrynbell, K-A-T-H-R-Y-N. Yeah. Odd spelling.

Okay. Brilliant. I’ll make sure I add that in the show notes now by actually mentioning these factors, these extra things that you’ve learned to mitigate their risk. It’s stuff that you are already, we’re all doing, we’re all doing these things already, but if the patient doesn’t know you’re doing them, then their perception has changed.

So it’s actually, this is a communication skill element that you’re letting the patient know that you’re going approach it in a certain way to minimize this risk and that risk. But sometimes we do that anyway, but we never verbalize it to our patients. So it’s not to consent is an opportunity to show yourself off as a fantastic communicator and to really instill and maintain that level of trust that a patient has in you.

Absolutely is gaining their confidence. It’s like, okay, so this could happen, but my practitioner is doing this and I feel safe about that.

It’s a missed opportunity otherwise, because we’re saying all these bad things that can happen, but also it’s an opportunity for us to show how fantastic we are and how much care we take to mitigate those. So this is probably one of my favorite pearls. Thank you so much.

Thank you.

So, Katherine, one more thing based on these red flags and stuff is some of my mentors have taught me that be careful with patients who are actively depressed. They are suffering with this horrible thing, depression.

Because not because we’re biased against people with depression. It’s nothing to do with that at all. It’s because their mindset for a big change when it comes to aesthetics and how they look they might not be in the best place to receive that and also especially I think it’s targeted towards those patients who feel or if you get this vibe that they are seeking this treatment as a therapy for their depression. If I only my teeth will look nicer, if only my lips will look fuller, that maybe I won’t be so miserable all the time. Is this something that perhaps you’ve noticed or been taught or reflected on?

It’s 100 percent something that I’ve noticed. So it’s very, very common, especially with women. So you go through a big breakup. The first thing you do is go and have a haircut. Like guaranteed. I know I’ve been there myself. So it is that you are seeking to do something that’s going to make you feel better. And I regularly see it in my book.

Maybe even feel different, feel changed, like a brand new person.

Absolutely. So a new start, fresh start. And for that reason, that’s fine. But like you say, when it’s true depression, that is something completely different because your reality is distorted. When you’re in a genuine depression and you don’t want to because at that point you can make big changes and then you’re going to regret the matter at a later date, and you’ve got to be so careful.

And again, it’s kind of wording. It’s like, maybe this isn’t the right time to be doing this. How about we put a pin in it and we readdress this, maybe we’ll do something minor like some skin treatments and let’s look at this again in maybe a few months once we’ve got your skin health glowing, skin glowing, we’ll get that first because that’s something small that can still make a big difference.

But if we’re looking at kind of big changes, then maybe in a genuine depression, it’s not the right time to be doing it. But then again, a couple of patients I’ve had where they’ve been through a recent divorce or again, another patient whose husband died and they’re not truly depressed, but it is that kind of, I want a new start. I want to feel good about myself.

That internal motivation is slightly different then, isn’t it?

Absolutely. It is. And it’s very subtle. So you do have to be super careful about is this person making, again, it’s kind of down to mental capacity, do they have the mental capacity to make this decision at this moment in time?

Because mental capacity isn’t just down to things like Alzheimer’s, but that’s the thing that I think we automatically think of is dementia when it comes to mental capacity, but also it is things like depression. Where-

Is there a mist? Is there a mist that they’re not able to see clearly at this moment in time?

Absolutely. So it’s kind of trying to weed out what is the internal motivation for them seeking this treatment at this moment in time. And that is one of my questions is why do you want this done now? Why is now the right time for you? And that is key in my consultation, is, why are you seeking this now?

Why not 10 years ago? Why not even a year, you decided, what is the reason for that? And it’s great because it really does, it’s up for some people it’s as simple as, well, it’s my 50th birthday next year. Something like that. And great. Why not? We can help you with that.

I guess I can liken this a bit to when we do our elective cosmetic procedures, whether it’s a diastema closure or whitening followed by some bonding or ceramic veneers. None of that can happen if there’s active perio and active caries. Now, when we are treating someone in terms of their perception of how their face looks or their aging, that is almost treating the mind in a way.

And how they see it. So we’ve got to make sure that the active, it’s horrible to call it disease, but it’s a suffering. It’s not nice, basically, but it’s something that they get that treat careful, right? It is an illness. You’re right. And so therefore, maybe we should adopt this mentality that no primary disease or the motivations for of it should not be related to the disease, basically, or the illness in that way.

So just a reflection there. I keep bringing it back to general dentistry because that’s all I know, but it’s been great to have your input in facial aesthetics. Honestly, I never thought I’d enjoy a topic about facial aesthetics as much as I have done. Maybe it’s because of you and it’s been so nice to speak with you. So tell us about, do you do any sort of talks, webinars, that kind of stuff?

I’d love to. And actually kind of going down the route of doing some training is definitely something that I’d really love to do. I’ve just got to find the right outlet for me to do that. Because I love educating.

Put it this way, Katherine, you know Intaglio is coming soon, right?

Yes, yes, yes. No, I think I’m already registered.

I would love for you to be one of the mentors. Yes, you are, you are. You’d be a great mentor for this because this is a space where especially feeling nervous about risk and stuff to have your first 10 cases handheld, practice visits all via zoom or whatever to go over the images and have that coaching and stuff. So, you already signed up to Intaglio. Amazing. So we’re at three or four weeks away from actually making mentor profiles and stuff, so I’ll be able to reach out.

Hi guys. Erika here from Team Protrusive. If you’re interested in being a mentor or you want to be a mentee who’s seeking for a mentor, then there’s a new platform coming out designed by dentists to help make mentorship accessible no matter which side you sit it on. Register your interest now on www.intagliomentoring.com.

But I would say anyone who’s thinking about facial aesthetics. Have they got your permission to for them to reach out to you, whether on Protrusive Guidance or Instagram, just to maybe just get that extra inspiration?

100%. I’d love, I’d love to do that. I’m more than happy to support other people going down this road. Yeah, definitely.

Amazing. Well, thanks so much. I’ve thoroughly enjoyed this conversation and the parallels with my general restorative dentistry and it’s been absolutely fantastic. Thank you so much.

No, my pleasure. My pleasure. It’s been lovely. Thank you so much for inviting me on.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. Once again, wasn’t that absolutely brilliant? Even like me, if you’re not into facial aesthetics and you gained a lot, I’m sure I certainly did. It was great validation of some of the communication things I do like when I’m consenting patients.

And just for me to remember that actually the whole thing about beauty is in the eye of the beholder. It’s already affecting us day to day in our dentistry that we already do, especially if we’re doing any anterior aesthetic work. If you’ve been inspired by Katherine, then please join us on Protrusive Guidance.

This is our own platform. You don’t need the Facebook group. You don’t need Facebook altogether anymore. If the only reason you come on Facebook is for the Protrusive Dental Community, then don’t bother. Go to Protrusive Guidance. The website is protrusive. app. You can even make a free account. We are verifying each individual.

It’s a manual human process because I want this to be a safe and secure space for us all. And if you’ve been waiting a few days and you haven’t heard anything, please email Mari. mari@protrusive.co.Uk. She’s our CPD queen, but also she’s in charge of making sure that we only let the legit people into our little community, our little network, which is actually growing at a rapid rate.

And it’s great to see you all on there. But the beautiful thing here is to get hold of me on Instagram is tricky, right? To get hold of me by email, I’m managing quite well. We’ve got a whole team approach to managing our emails, but the best way to get in touch with me and any of the other Protruserati, including our guest, Katherine, is by the DM mode that we have on Protrusive Guidance.

Like if you download the app, you can DM me, you can DM anyone. I’ll always prioritize Protrusive Guidance and the emails, of course. Whether you go for a free plan or a paid plan. If you’re looking for CPD, you are all welcome. Now, speaking of CPD, this episode is eligible for 35 minutes of CPD or CE, and all you have to do is answer our quiz.

One of the questions that we had, see if you can answer this one, is which of these are a red flag for considering facial aesthetics or any aesthetic work? Is it A. Body dysmorphia? Is it B. Depression and the end goal is relating to the depression? Is it C. Is it OCD and holding a zoomed in mirror very close to your face? Or is it D. All of the above.

Okay, that was an easy one. There are some hard ones and easy ones as always as we need to, but part of the testing is to make sure that you actually did listen all the way to recall the information, but also to test your knowledge. And the way you can get involved with the CPD quiz is on the app.

So it could be either by the website, protrusive. app, using on a browser or on your mobile phone, once you download the native app. And if you’re one of our paid plans at the protrusive premium CE plan, which is like, if you want to get CPD just from the podcast episodes, great. Join us on that. If you want the ultimate education plan, then you get access to all our courses as well, which is like VertiPrep for Plonkers, Sectioning School, Quick Slick Rubber Dam, and of course, all the webinars and our monthly premium content that we’re making just for you guys.

Thanks so much for joining us all the way to the end once again, and catch you same time, same place next week. Bye for now.

Hosted by
Jaz Gulati

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