The Patients We Don’t Treat: Why Saying No Is Part of the Job

There’s an old line in dentistry that I’ve never forgotten. You build your reputation by the patients you don’t treat. The first time I heard it I thought it was a bit of a paradox. The longer I’ve practised, the more I think it might be the truest sentence in our profession.

This is the final piece in my five-part series on the way I think about my work at BDS Dental. The first four pieces have been about what we do — preserving natural tooth, choosing the conservative restoration, getting prevention right. This piece is about what we don’t do, and why I think the work you decline is just as important as the work you accept.

The daughter test

Before I get into specifics, let me explain a phrase I find myself coming back to over and over in my own head when I’m working out whether a course of treatment is right for somebody. Would I do this to my own daughter? Would I be happy to do this to my own son? Would I be happy to have this done on myself?

That’s it. That’s the test. It sounds simple, almost trite. It isn’t. The reason it works is that it forces an honest answer past all the noise — past the patient’s strong preferences, past the financial implications, past the social pressure to give the patient what they’re asking for. If the answer is, yes, this would be the right call for someone I love, that tells me something. If the answer is no, I would talk my own child out of this, then I have to be willing to talk this patient out of it too.

It’s the same test for everyone in front of me. It doesn’t matter whether the patient is wealthy, or insistent, or has been a patient of mine for twenty years. The daughter test is the same test. And if I’m not willing to apply it consistently, I shouldn’t be in this job.

The eighteen-year-old who wants eight veneers

The most common version of this conversation in my chair is some variation of the following. A young patient comes in, perhaps eighteen, perhaps in their early twenties, with naturally healthy front teeth, and asks for veneers. Six of them. Sometimes eight. The trigger is almost always something they’ve seen on social media — a particular smile, a particular shade of white, a particular look that has become the unofficial signature of modern cosmetic dentistry.

When I run the daughter test, the answer in those cases is unambiguous. No. I would absolutely not subject my own daughter to that course of treatment on healthy front teeth.

So I won’t do it. Not under any persuasion. There’s no version of this where I will fit veneers on eight perfectly healthy front teeth of an eighteen-year-old.

What I will do is have the conversation. I’ll sit with the patient and explain, properly, what they’re actually agreeing to. I’ll explain how much enamel needs to be removed for a veneer to look right, and that the enamel doesn’t grow back. I’ll walk them through the lifetime maths — that veneers last ten to fifteen years, that round two takes a little more tooth, that round three takes a little more again, and that by the time they’re in their fifties or sixties the teeth I’m being asked to start work on at eighteen are likely to have become crowns, possibly with root canals, possibly extracted and replaced with implants.

When I lay out the actual forty-year picture in plain language, the majority of patients change their minds. Almost everyone, in fact. Some of them go for whitening instead — which is essentially reversible and doesn’t damage the teeth — and discover that they’re much happier than they expected to be with the result. Some come back a year or two later to see whether a couple of small bits of bonding might refine the shape a little. A few do go elsewhere and get the veneers done by another practice, and there’s nothing I can do about that. But my job, as I see it, is to give them the information they need to make the decision properly. Where I can’t do that and still feel comfortable carrying out the work, I won’t.

Where I will agree to do something I’d rather not

I want to be honest, though, that the ethics of this aren’t always black and white. There are grey areas, and it’s worth being upfront about how I navigate them.

A common one is patients asking for their old metal amalgam fillings to be removed and replaced with tooth-coloured ones. Now, sometimes the fillings genuinely need to come out — they’re failing, there’s leakage, there’s decay underneath, and replacement is the right call. In those cases I happily replace them, and I use modern materials and bonded composite techniques because amalgam isn’t what I work with any more.

But what about a sound metal filling that’s been in the patient’s mouth for twenty-five years and is doing a perfectly good job? My honest advice is don’t touch it. Drilling out a working filling to replace it has a real biological cost — we’re removing extra tooth structure to access the old filling, and there’s a small but genuine risk that the tooth ends up needing more work as a result. If the filling is sound, the right answer is usually to leave it alone and replace it for something tooth-coloured when it actually needs replacing.

When I explain this, most patients are persuaded. But occasionally I get a patient who has read something, made up their mind, and is going to have those fillings out one way or another. In those cases, I will sometimes agree to do the work, even though I’d rather not. The reasoning is simple: if they’re going to get this done somewhere, I would rather be the one doing it. I can remove old amalgam carefully under proper rubber-dam isolation, which prevents the patient from inhaling or swallowing material during the removal, and I can replace it to a high standard. The alternative — telling them no and watching them walk into a less careful practice — isn’t actually in their interest.

So there are grey areas. The line isn’t I will always refuse anything I personally would not have done. The line is I won’t do anything I think is actively harmful, and where I’ll do something I’d rather not, I’ll do it to a standard that protects the patient as much as possible.

What this looks like from the patient’s side

I think the patient experience of this is what matters most, so let me describe it as I see it from the chair.

A patient comes in for a consultation. They’ve been quoted something elsewhere — a course of cosmetic work, an extraction, multiple fillings — and they want a second opinion. I look at the x-rays, I examine the teeth, and I tell them what I would actually do. Sometimes the answer is yes, all of that work is necessary, the original treatment plan is sound. Sometimes it’s most of that is necessary, but I’d do this one differently. Sometimes it’s I wouldn’t do any of that — I’d watch it, I’d improve your hygiene, I’d review you in six months. Occasionally it’s I think you’ve been advised to have work done that you don’t need, and I’d encourage you to walk away.

Patients sometimes leave my chair having been told that the treatment they were preparing themselves financially and emotionally for is, in my view, simply not the right thing to do. They thought they were coming in for veneers, and they’re leaving with the advice to whiten their teeth and see how they feel. They thought they needed an extraction, and I think the tooth can be saved. They thought they needed eight crowns, and I think they need two.

The strange thing is, that conversation — I won’t do this to you, and here’s why — is often the moment the patient becomes a patient of this practice for life.

I think it works because it’s the moment they realise that I’m not financially incentivised to do work on them. That my opinion isn’t being shaped by my next car payment. That when I do recommend treatment, in the future, they can trust that I genuinely believe it’s the right call — because they’ve already heard me say no to work I could easily have agreed to do.

Why trust is the actual product

When I started in this practice in 2001, what attracted me to Harris Sidelsky’s way of working was exactly this. He wasn’t just clinically excellent. He was trustworthy. Patients understood that he wasn’t trying to sell them treatment they didn’t need, and that single fact bound them to him for decades. Many of his patients are still patients of mine and Ellie’s now, sometimes spanning generations of the same family — and that doesn’t happen by accident. It happens because trust was the actual product, and the dentistry was the thing trust was applied to.

The longer I’ve practised, the more I’ve come to think that the underlying thing patients are buying when they choose a private dentist isn’t really the clinical work, although of course that has to be excellent. It’s the relationship with someone whose judgement they trust. The clinical work flows from that. The trust is the foundation.

This is also why I take the long view on declining work. In the short term, saying no to an eighteen-year-old who wants eight veneers means we don’t take the money for that case. We aren’t going to be persuaded to do it. But that conversation, done properly, is the start of a forty-year relationship with that patient. They’ll come back with their children. They’ll send their friends. They’ll be the patient who calls us first when something does go wrong, because they know we’ll deal with it straight.

You can build a different kind of practice if you take every case the door brings in. You’ll have a busier year. I don’t think you’ll have a better practice.

A summary of the series

This is the last piece in the series, so let me draw the five articles together briefly.

The first piece was about my path into dentistry, and how a year studying psychology during my dental degree shaped the way I listen to patients.

The second was the underlying fact I think every dentist should be making clearer to every patient — that teeth, alone among the structures in your body, don’t repair themselves. Which is why prevention matters more for teeth than almost anywhere else, and why we should always remove as little as we can.

The third was about the clinical choices that follow from that. Onlays preserve more tooth than crowns. Veneers on healthy young teeth start a slippery slope. The conservative option is almost always the right one, and most patients have never been walked through it properly.

The fourth was about the Five Fs of prevention — fluoride, food, fissure sealants, floss, and a friendly dentist — and why flossing, of all of them, is the habit most patients are missing.

And this piece, the fifth, is about the work we don’t do, and why declining the wrong cases is, in some sense, the test of whether a dentist is the right one for you.

Thank you for reading. If anything in this series has resonated — whether you’ve been quoted for work you’re not sure you need, you’ve been wondering about veneers, or you’d just like a check-up with a dentist whose first question isn’t what work shall we do next — please come in and have a conversation with us. A consultation isn’t a commitment to anything. Sometimes the most useful thing I can tell a patient is that they don’t need anything at all. That’s a perfectly good outcome, and one I’m always happy to deliver.

Dr Ian Davis is a partner at BDS Dental. To book a consultation or a second opinion on treatment you’ve been offered elsewhere, contact the practice here.