Why Gold in an Era of Cosmetic Dentistry?
Article by Joseph F. Newell, D.D.S.
 -- pending publication by Compendium, journal for Dental Professionals

“Cosmetic Dentistry” is everywhere.  Many, if not all dentist considers themselves cosmetic dentists.  From television’s “Extreme Makeover“ to every advertisement in newspapers or magazines, cosmetic dentistry takes the forefront in mass appeal by the public.

This is a great opportunity for dentistry.  As patients, self esteem and confidence is greatly enhanced with a beautiful smile.  Many patients, who might otherwise not seek dental care, are persuaded to see a dentist for cosmetic reasons and that can lead to healthier oral care for the entire mouth.  There is a substantial amount of the population that seeks dental care for these reasons.

There is also a substantial amount of the population that is not looking for a cosmetic makeover.  The reason most patients see a dentist on a regular basis is to simply maintain a healthy dentition.  They don’t want to lose their teeth.  If they need restorative care, they want their restorations to feel good and last a long time. If they are cosmetic or white restorations, patients will readily accept that treatment.

But cosmetics is not the prime reason for choosing a composite or porcelain restoration.  Health, comfort, and longevity are the prime factors in a patient’s decision-making process when choosing a restorative material along with reducing the least amount of tooth structure.  Cosmetics are secondary.

The patient relies on the dentist to select the most appropriate material to correct a problem.  The dentist relies on his knowledge, clinical skills, and experience and comfort level when he or she selects a restorative material.  Many times, the dentist assumes the patient only wants cosmetic restorations, even in posterior regions of the mouth, well outside the esthetic zone.

Patients are willing to subject themselves to dental procedures so that their mouth feels good and functions properly.  Their fear and anxiety levels increase with the thought of the dentist anesthetizing and preparing teeth.  Some patients are shocked and disappointed at the amount of tooth structure removed in order to rehabilitate a tooth.

For patients who do not consider cosmetics a priority for dental treatment, cast gold and gold foil restorations offer a superlative choice for restorative material recommendations.  The Journal of the American Dental Association in 2003 stated that “ Cast gold is the standard by which other dental materials are measured.”  This continues to be true today.  Cast gold is unquestionably the best restorative material available to the dental profession along with gold foil.  These materials, if manipulated and placed at the highest levels, can indeed last for a patient’s lifetime.

Cast gold is the most biocompatible material used in dentistry today.  It is non-corrosive and hypo-allergenic.  It’s wear rates and coefficient of thermal expansion is very similar to enamel.  Gold margins do not break or chip even when thinned and polished.  Less tooth structure is removed when preparing teeth for gold, which leaves the tooth stronger and healthier.

However the greatest advantage of using gold is its longevity.  It easily outlasts other materials three to five times longer.  When describing other materials, we talk in terms of years of service.  When talking about cast gold, we speak in terms of decades of service.  This idea is not lost on patients and it is a huge motivating factor for them to select gold.

For cast gold and gold foil restorations to achieve decades of service, they must be placed with the highest levels of skill and precision.  The use of rubber dam, magnification, hand instruments and sharpeners is imperative.  Outstanding laboratory support is critical.  Clinical study club participation helps immensely with training and experience to develop the expertise to deliver high quality gold castings.  Excellence is the goal for every step in the process of fabricating gold restorations.

One such study club that teaches and promotes excellence in the use of cast gold is the Academy of R.V.Tucker Cast Gold Study Clubs.  When using Dr. Tucker’s technique for cast gold, there is minimal display of gold.  (See figures 1,2 and 3)

The gold outline form is essentially the same as amalgam.  Defective amalgams are usually replaced with gold castings as in figures 4 and 5.  Patients appreciate the high precision and craftsmanship that gold restorations require.  Delivering gold castings requires time and dedication to perfection.

The finishing and polishing procedure makes the gold margins imperceptible to an explorer’s touch.  Gold foil like margins can be achieved.  When fully polished, the entire tooth feels like glass because optical polishing agents are used.  (See figure 6)

Castings are very conservative in their nature.  Full crowns can be avoided with judicial use of retention forms such as pins, slots, potholes and bales.  Sometimes it seems that full crowns are the treatment of choice for many dentists because it is easy and predictable but it may not be the best choice for the patient.  Dentists should be compensated for how much tooth structure is saved, not by how much is destroyed.

Patients have a right to excellence.  They assume that whatever the dentist does is the best that can be done for a particular problem.  They also assume that the best materials are being used.  As an example, if a cardiologist tells a patient that he needs a new heart valve, the patient assumes that the best heart valve on the market will be used.  Not informing patients that gold is a viable option to restore a tooth shortchanges the patient and the dentist.  He or she has lost the opportunity to provide the very best service for a patient that might want the best.

Patients readily accept gold if it does not appear in the esthetic zone.  They are especially happy at the thought that these restorations, if done properly, could last their lifetime.  As life expectancies increase, material choice is important to reduce the number of times restorations must be replaced.  Constant trauma to teeth leads to pulpal inflammation and necrosis, root canal therapy and crowns.  Restoring a tooth once is very appealing to patients.

There has been a shift in dentistry recently to use cosmetic restorations everywhere in the mouth.  "Comprehensive Dentistry" should be used to describe the modern dentist where cosmetic dentistry is just one aspect of total patient care.  Dentists should recommend the best material for each individual situation to the patient.  After educating the patient about the advantages and disadvantages of different materials, a mutual informed decision could be made.  It is personally and professionally very rewarding for the dentist to know that they have done the best for the patient.   Gold restorations have a place in dentistry today along with cosmetic dentistry.

There is a learning curve in providing this service and training is required to perform these procedures at the highest level.  The Academy of R.V.Tucker Cast Gold Study Clubs is one such program that can train dentists in these procedures.  To learn more, visit the website www.RVTucker.org.