Sir, I hasten to reassure Mr Hassall1 that my approach to moderate wear cases such as he showed (Fig. 17 [Fig. 1])2,3involves informing patients about all the available options (including ‘no treatment'), along with pros and cons, with their autonomy always being respected. Once those options are explained fairly, including that ‘nothing in dentistry is either perfect or permanent', my patients have nearly always chosen the least destructive approach to preserve the maximum amount of their remaining healthy tooth tissue.

Fig. 1
figure 1

Figure 17 of the original paper. Reproduced with permission from D. Hassall, ‘The use of the monolithic ceramic and direct monolithic composite in the aesthetic rehabilitation of tooth wear', Br Dent J 2023; 234: 406-4122

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In the case that Mr Hassall showed, the patient lost serious amounts of their sound tooth structure (Fig. 23 [Fig. 2])2,3 electively, to ‘gain' the dubious aesthetics of over-contoured monochromatic monolithic zirconia, with periodontal inflammation as a side effect (Fig. 27 [Fig. 3]).2,3

Fig. 2
figure 2

Figure 23 of the original paper. Reproduced with permission from D. Hassall, ‘The use of the monolithic ceramic and direct monolithic composite in the aesthetic rehabilitation of tooth wear', Br Dent J 2023; 234: 406-4122

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Fig. 3
figure 3

Figure 27 of the original paper. Reproduced with permission from D. Hassall, ‘The use of the monolithic ceramic and direct monolithic composite in the aesthetic rehabilitation of tooth wear', Br Dent J 2023; 234: 406-4122

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For most people, the psychologic pain of losing something valuable is twice as powerful as the pleasure of gaining something in return. ‘Loss aversion' in humans can be summarised by the dictum ‘losses loom larger than gains'.4

If people genuinely understood that they were electing to lose about 30 years' worth of their worn - but healthy - tooth structure by rapid diamond bur abrasion (Fig. 23 [Fig. 2])2,3 for a questionable ‘cosmetic gain' (Figs 17 vs 27 [Fig. 1 vs 3])2,3 they might well prefer to keep what they had for their later life. Their psychologic pain about loss of their irreplaceable marginal ridges would be compounded by the realisation that they had paid handsomely for that alleged restoration durability with their sound tooth structure, presumably money, and periodontal inflammation (Fig. 27 [Fig. 3]).2,3

Many rational patients, if they could really visualise the biologic damage being done electively to their teeth for such a long-term dubious gain, or genuinely understand the hard figures of losing up to 30% for ceramic veneers, or up to 63% for full coverage-all ceramic crowns,5 would choose to keep those slightly worn teeth. If they really wanted an improvement in their smile, most would happily choose a ‘bleaching and bonding approach', using some repairable and renewable composite, done with adequate skill to achieve a ‘satisficing' result (meaning one that is sufficient to be satisfactory). If there happened to be some minor staining or chipping years later, they would be comforted by not having lost the structural strength of their marginal ridges and having an almost identical fall-back position to their original situation for further direct composite bonding.

My advice for Mr Hassall is: ‘Beautiful enamel lasts longest etched not drilled'.