Dr. Ronald E.
Ronald E. Goldstein
Dr. Goldstein, the inaugural recipient of the NYU Irwin
Smigel Prize in Aesthetic Dentistry, is a cofounder and past president
of the American Academy of Esthetic Dentistry, a past president
of the International Federation for Esthetic Dentistry, and holds
professorships at the Medical College of Georgia, the University
of Southern California, Boston University, and the University of
Texas Health Science Center.
Health Nexus (GHN): Dr. Goldstein, how did your approach
to esthetic dentistry evolve?
Dr. Goldstein: After I completed the first two
studies on factors motivating dentists toward esthetics in dentistry,
published in The Journal of Prosthetic Dentistry in 1968, I began
to map out a concept of what needed to be done in order to expand
dentistry’s preoccupation with occlusion and function of the
stomatognathic system in order to incorporate esthetics as well.
I then spent seven years working on what would become the first
comprehensive interdisciplinary textbook on esthetic dentistry,
Esthetics in Dentistry (J.P. Lippincott Publishing, 1976; B.C. Decker
Publishing, 1998), which addressed the role of each dental specialty,
plus plastic surgery and cosmetology, in making the total face more
attractive. This was followed by Change Your Smile (Quintessence
Publishing, 1984), a comprehensive consumer guide written in response
to a thirst for knowledge that had been stoked by the media.
GHN: What role did consumer demand play in dentistry’s
decision to embrace esthetics?
Dr. Goldstein: Beginning in the mid-1960s, consumers
began to feel that gold and silver restorations were no longer attractive
or natural looking, especially given the “black smiles”
that silver produced. So, in order to satisfy the patient’s
desire for a more attractive smile, dentists began to experiment
with tooth-colored filling materials which were esthetically attractive,
but which failed miserably in life expectancy.
Then, in 1965, I received a call from Dr. Michael Buonocore, a co-inventor
of the BisGMA formula, who told me that he and Dr. Raphael Bowen
had developed a material that would repair fractured teeth, and
they wanted to know what else it might be used for esthetically.
My challenge was to come up with various esthetic techniques and
to let him know specifically which ones endured over a period of
time. In fact, when I received the first batches of the material,
there was no manufacturer’s name attached to the labeling.
(The material later became known as 3M’s Addent.) You cannot
believe how excited I was to be utilizing material that enabled
us to achieve immediate transformations of esthetic deformities.
This is when we came up with techniques such as closing spaces,
building out teeth to create the illusion of straighter teeth, and
masking discolored teeth.
I still recall the excitement of dentists when I reported my five-year
results, showing that not only was instant transformation possible,
but that it held up as well. However, the polishability, staining,
and self-curing nature of the composites were limiting factors.
This motivated manufacturers to develop microfill to be used in
“sandwich techniques” to make the restorations look
This still left the problem of the self-cured restorations, which
cured too fast and were difficult for dentists to use. You had to
work extremely fast to get the desired shape. So experimentation
continued and in 1972 the next advance arrived: light-cured composites.
This time I received a call from L. D. Caulk, announcing that they
had developed a material that could be cured with an ultraviolet
light, and informing me that they were sending me a prototype of
the first curing light, and that I would have 90 days to evaluate
it. When the light arrived, it was actually chained to a courier,
and he would not take the chain off the package until he was ushered
into my operatory and could release it into my personal care. This
was a huge ultraviolet light, using a material called Nuvafill,
but the results were spectacular. Despite a negative response from
the profession, I predicted that these lights would be effective,
and they have since far exceeded my predictions to become the gold
standard for functional and esthetic procedures today.
GHN: In addition to the shift in emphasis from function
to esthetics in dentistry and the advent of improved materials,
what other factors helped bring about the esthetic revolution?
Dr. Goldstein: The economics of esthetic dentistry
also helped to popularize the field. Suddenly, people who could
not afford gold restorations and did not like the appearance of
silver were able to have a bonded restoration for 20 to 25 percent
of the cost of a crown. And even if the restoration had to be replaced
later, it was still more affordable than the cost of one crown.
Finally, the ability to show patients what they would look like
prior to treatment, using computer imaging or “trial smiles,”
has been a major factor in helping to convince Americans that, by
giving them great smiles, dentists could enhance their appearance
and self esteem — a skill previously associated mainly with
GHN: As the esthetic revolution has advanced, have
there been drawbacks?
Dr. Goldstein: Once a national conversation about
dental esthetics got under way, much of the information being disseminated
was inaccurate, not easily accessible, or the results shown in the
media were not reproducible.
Moreover, not all dentists are equally proficient in esthetics.
There were and still are many costly esthetic failures, with a loss
to patients of approximately $13 billion annually. In a course I
teach called “Esthetic Failures,” I am adamant that
as a profession we need to do a better job of referring patients
for esthetic dentistry to the most skilled professionals. Indeed,
I always tell consumers: “Match your desire for esthetic dentistry
with the dentist’s ability to provide it for you.”
We also need to do a better job training our colleagues to recognize,
and avoid, patients who are body dysmorphic — who believe
that by changing their smiles, all the problems in their lives will
be solved. In those cases, failure is virtually guaranteed.