Revisiting 'The Daughter Test'

Martin Kelleher introduced the concept of 'The Daughter Test' in 2010.¹ Simply stated, the test asks, when considering elective cosmetic dentistry, 'Knowing what I know about what this procedure would involve to the teeth in the long term, would I carry out this procedure on my own daughter?' In the 12 years since, the dental landscape has changed dramatically. Dentists and patients have a wider range of cosmetic treatments available, the law surrounding consent has changed, and a culture of fear has arisen around litigation and regulatory investigation. With all this in mind, now seems an ideal time to revisit The Daughter Test and its relevance to today's dentistry.

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At the heart of the original Daughter Test was dismay at the apparent overzealousness of dentists to prepare otherwise healthy teeth for veneers and full-coverage crowns solely for cosmetic reasons. Until recently, dentists appeared to have taken the message on board, with a renewed emphasis on minimally invasive aesthetic treatment, often involving cosmetically focused orthodontics in conjunction with tooth whitening and minimal composite bonding. However, recent innovations have come along to threaten the nation's healthy enamel.

For example, the computer-aided composite veneer smile makeover has recently gained significant publicity. This treatment modality is marketed as minimally invasive and accompanied by slick videos from self-professed celebrity dentists concentrating on their specific method's speed, efficiency and profitability. While there's no doubt that this treatment can produce excellent aesthetic results, there seems to be less discussion of what happens when these veneers need replacing. Composite veneers require significant upkeep to remain aesthetically pleasing. It's likely that in 5-10 years, we will see many disgruntled patients needing replacements and even more disgruntled dentists spending hours trying to remove layers of composite without damaging enamel. Are we unnecessarily introducing a new cohort of patients into the restorative cycle under the pretence of minimally invasive dentistry? Would many of these cases be more suited to a more traditional, longer-lasting ceramic approach?

The original Daughter Test concentrated on destroying enamel for cosmetic purposes, mainly because that was all that was available to dentists at the time. In the intervening years, the march of patient autonomy has been relentless, with many practitioners feeling pressured into carrying out treatments they oppose due to demanding patients. In our quest to avoid porcelain, have we forgotten that, often, what's best for teeth is teeth and that no synthetic replacement, be it ceramic or composite, is an ideal substitute? As dentists, we have autonomy over the treatment we provide, including not providing the treatment a patient may be demanding.

Kelleher's initial warnings over 'hyperenamelosis' and 'porcelain deficiency disease' now have a new companion. Teeth do not suffer from 'composite insufficiency', no matter how many celebrity dentists tell you they do. Patient autonomy might rule the ethical roost for now. However, we are still the experts and should be able to cast a critical eye over new modalities as they appear and judge if they're suitable for our patients, daughters or not.