By Rita Zeidner
Special to The Washington Post
Tuesday, May 18, 2010; HE01
When Carla Morelli made an appointment for a routine checkup at the Kentlands Dental Care in Gaithersburg, she didn't request a cosmetic consultation. But that didn't stop clinic staffers from offering up beauty advice.
First to weigh in was the hygienist who cleaned her teeth. After telling Morelli how much prettier she would look if she got her teeth straightened, she urged her to consider being fitted for Invisalign, clear plastic braces that would slowly move her teeth into place.
"Until she told me, I never knew there was a problem with my smile," recalled Morelli, 39, owner of a Gaithersburg financial services consultancy. She pulled down her lower lip to expose a slight buckling of her front bottom teeth.
After telling the hygienist she wasn't interested, Morelli said, she forgot about the incident until a follow-up visit last year, when several other staffers approached her about Invisalign. One said the braces would prevent her teeth from spreading and head off more-serious mouth and gum problems.
Morelli briefly considered making the investment, which averages $5,000. But because no dentist she had seen elsewhere had told her she needed braces -- nor, in fact, did the dentist she saw at Kentlands -- she began to get annoyed. Rather than a patient getting advice, she felt like a customer being pressured.
"The staff just seemed programmed to talk about Invisalign," she said.
She became even more irritated when several of her own employees said they had been pressed to look into Invisalign while having their teeth checked at Kentlands, the only nearby clinic that takes the insurance offered through Morelli's firm. (It is not related to the similarly named Kentlands Dental and Orthodontics group, which is also nearby.) The clinic also advertises the product on its Web site, on its recorded on-hold message and in a flier posted on a street-facing window.A blurry line
Concerns such as Morelli's may become a common theme among consumers, as elective cosmetic treatments are increasingly available from the same providers whom patients turn to for medical advice.
Plastic surgeons are still the doctors most commonly associated with purely cosmetic treatments such as Botox injections, facelifts and tummy tucks. But similar elective procedures -- which generally aren't covered by insurance -- are being offered by a wide variety of specialists. Many dermatologists, who treat patients for skin cancer and other diseases, also promote treatments to smooth wrinkles, lighten age spots and remove hair. Otolarnygologists, who care for patients with conditions of the ear, nose and throat, commonly perform nose jobs, brow lifts and eyelid surgery.
Teeth whitening, veneers and Invisalign, along with more painful and costly gum surgery, are among the treatments many dentists and periodontists promote for adults as part of a "smile makeover."
Of course, just because a treatment has cosmetic benefits doesn't mean that it isn't medically beneficial or that it won't be covered by insurance. Breast augmentation, for example, may be covered by insurance following a partial mastectomy, but not if you're healthy and just want to increase your cup size. Similarly, insurance may pay for surgery if your droopy lids are getting in the way of your vision, not if you simply want to look younger.
Patients who don't demand to know why a particular treatment has been recommended risk unexpected out-of-pocket expenses, inconvenience and unnecessary pain, said Kenneth Greer, a professor at the University of Virginia School of Medicine and the recently retired chair of the school's dermatology department. "I would never say doctors are deliberately misleading patients," he said. "But like with many things in life, it's caveat emptor."Patient education
Several providers interviewed for this article said recommending products and services that improve a patient's appearance, even to those who never asked for such advice, is part of patient education.
"Every single staff member definitely makes sure that a patient knows all their options," said Zivile Balaisyte, the patient coordinator at Kentlands, the dental clinic that recommended Invisalign to Morelli. "That's part of our approach."
You don't have to be a brain surgeon to understand why health-care practitioners might be interested in offering cosmetic services. Just follow the money.
Last year, Americans spent nearly $10.5 billion on cosmetic procedures, according to the American Society for Aesthetic Plastic Surgery, an increase of nearly 150 percent in the past 12 years. (About $4.5 billion went toward relatively noninvasive procedures such as Botox injections to smooth wrinkles and lasers to remove hair and erase skin blemishes. The remainder was spent on surgeries, most commonly breast augmentation, liposuction and eyelid lifts.)
In 2009, a year when many consumers cut back dramatically on nonessential purchases, the number of cosmetic procedures performed by members of the American Academy of Cosmetic Surgery grew by 8 percent, according to a separate report. "With the aging of the baby boomer generation, I don't think we've come close to hitting the ceiling yet," AACS President Mark Berman said in a press release.
In 2006, the last year for which data are available, American adults spent $511 million on teeth bleaching and veneers, according to the American Academy of Cosmetic Dentistry. Cosmetic-related dental revenue rose 15 percent between 2005 and 2007. (That figure includes procedures necessary to protect or improve oral health.)
Crooked teeth may not bother many people, but they often signal the start of a more serious mouth problem, said Roxana Homayoun, an orthodontist and owner of Kentlands Dental Care.
Asked about Morelli's concerns, she said: "Invisalign does amazing work for adults, and we recommend that to patients who don't want to get [traditional] braces. You're not going to die if you don't get it, but it's very important to have straight teeth."
Periodontist Edgard El Chaar, a clinical associate professor at New York University's College of Dentistry, said he began suggesting specific cosmetic treatments to patients five years ago. He maintains that it is what patients expect.
"Nowadays patients are bombarded with information about cosmetic treatments," he said. "If you don't offer these services, patients get upset. And if they are available but you don't make patients aware, they ask, 'Why didn't you tell me?' " Still, he wonders if the approach is in the patient's best interest.
"I've seen patients offered treatments [by others] that weren't appropriate," he said.Motivated by profit?
There are few if any rules governing how doctors and dentists promote cosmetic treatments or make patients aware of their efficacy or risk.
Greer, the dermatology professor, said he has attended conferences where physicians described remarkable results from their pioneering cosmetic work. But when he examined their "before" and "after" photographs, he said, he saw little difference.
Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said he is concerned that profits are motivating some practitioners to overstate the benefits of cosmetic treatments. "It's a reality of human nature that if you're selling something, you're going to be positive about it," he said.
In the absence of professional or legal guidelines, "it's the patient's job to ask questions, to ask more questions and then to ask more questions."
Barbara Rappaport, an actress and professional narrator in Silver Spring, said she regrets she wasn't more inquisitive when she made an appointment at the Dermatology and Clinical Skin Care Center in Bethesda to have a rash examined last fall. When the physician she saw offered to remove a small brown mark on her temple, which she identified as sun damage, Rappaport agreed but says she didn't learn the treatment wasn't covered by insurance until she showed up for the procedure a month later and was asked for payment on the spot.
"The first words out of the doctor's mouth were to ask if we had discussed money," Rappaport said. "When I said no, she casually asked how $250 sounds."
Embarrassed, Rappaport agreed to go ahead with the procedure but immediately had regrets. Bruises, a common temporary side effect of laser treatments, left blotchy marks on her face for weeks. Worse: The brown spot is still visible.
Dermatologist Roberta Palestine, the clinic's founder and director, said she did not treat Rappaport and was not familiar with the details of her case, because Rappaport did not register a formal complaint. But she said Rappaport's experience, as described to her by a reporter, "would be very unlikely."
Indeed, it should be easy to see the difference between the medical and cosmetic sides of Palestine's practice. While medical patients report to a comfortable but run-of-the-mill waiting room, cosmetic patients are directed to a far more luxurious, spa-type setting one door down. There the floors are polished wood, the countertops stone and the lighting subdued, not fluorescent. New Age music plays in the background. Herbal teas are offered free of charge.
A two-tiered arrangement, in which cosmetic patients are treated to a higher level of pampering, is typical of a growing number of practices. "This one-stop is very convenient for patients," said Palestine. "Many of our patients have both medical and cosmetic questions during the same visit. We deal with their medical questions and send this portion to insurance, and we deal with their cosmetic questions and this does not go to insurance."
Rappaport said that distinction was not made clear to her when she agreed to the laser treatment.
In general, providers could do a better job clarifying for patients when the treatments they recommend are medically necessary, Caplan said. Distinguishing between cosmetic and medical treatments "is harder than doctors think it is," he said.
Providers could also be more forthcoming about out-of-pocket costs. When asked whether a treatment will be covered by insurance, doctors typically hem and haw about widely varying coverage policies, according to Caplan. In reality, they usually know which procedures are covered, he said, "to the dime."
Before agreeing to any treatment, he said, patients should nail down the facts about realistic outcomes, the risk of complications and whether the procedure needs to be done immediately.
Dental patients should demand a thorough explanation of "what's going on and why," said Annapolis dentist Scott Finlay. Although there are never guarantees, recent developments in two- and three-dimensional modeling give patients a fairly reliable idea of the likely outcome of a dental makeover and help ensure realistic expectations, he said. Patients should also ask to see "before" and "after" photographs of the provider's work.
For her part, Morelli has decided against getting Invisalign braces. Her new dentist, at a different practice, told her not to bother because she didn't need them.
"There is a difference between making you aware of a product," she said, "and ramming it down your throat."
Zeidner is a freelance writer in Arlington.