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AACD accreditation process changed my approach to aesthetic dentistry practice - Dr. Prashant Hatkar. (Photo: Dr. Prashant Hatkar)

Sat. 16 April 2022

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Dr. Prashant Hatkar MDS (Cons & Endo), Accredited Member, American Academy of Cosmetic Dentistry (AACD); Certified Member, European Society of Cosmetic Dentistry (ESCD), and well-known for his artistic work in aesthetic and cosmetic dentistry shares his journey and his take on how restorative dentistry will evolve in the coming years.

Can you tell us something about your initial years in Dentistry?

At the outset, I would like to thank you and the editorial team of Dental Tribune for approaching me for this interview. I am Dr. Prashant Hatkar and I did my graduate program in dentistry at Nair Dental College Mumbai in 1996. Thereafter I completed my masters’ program in conservative dentistry & endodontics in 1998 from Government Dental College Mumbai. My initial years were engaged in teaching as well as in specialty clinical practice as an endodontist. As a lecturer, I received very positive responses from my students then and that furthered my passion to acquire and share knowledge with fellow colleagues. My stint, as a consultant endodontist, with the well-known cosmetic dentist Dr. Sandesh Mayekar exposed me to a realm of dentistry that was never known to me or ever seen in dental schools. In his practice, dentistry to me came across as a very upmarket and glamourous profession, provided one has vision and acquires the right skills. This was certainly a game-changer in upping my own expectations from me as a dentist and my first exposure to esthetic dentistry. As I began my journey into my own practice in early 2003, I was fortunate to have stepped into an established practice in an esteemed location of Mumbai. The beginning was surely positive and we had a steady patient inflow, thanks to the goodwill of the practice we got into. However, soon I realized that you always have to stay ahead of your game to satisfy the expectations of your patients. My awareness of what I knew and what I could deliver to my patients only grew with the passage of time.

How and when did you develop the interest and passion for Aesthetic and Cosmetic Dentistry?

In the early part of my career, I was part of a study group with some highly motivated clinicians who used to meet informally every month to exchange ideas, clinical work, and the evolving philosophies in dentistry. Dental photography was an integral part of my practice from day one and that enabled me to share my work on such forums. In that study group, we had Dr. Ali Tunkiwala and Dr.Madhu Bendre who had already set their feet in the American Academy of Cosmetic Dentistry (AACD) accreditation process. In one of my personal meetings with Dr. Bendre at my clinic, I showed him one of my esthetic dentistry cases that instantly received critical feedback from him. I realized that my eyes were unable to see some fine nuances that Dr. Bendre could not only recognize but also objectively analyze. The way he detailed the faults of that case became a turning point and changed my understanding of the benefits of going through the accreditation process. My yearning to achieve excellence in esthetic dentistry soared high after learning about the entire accreditation process, its challenges, and the value additions that it could bring into anyone’s career.

Fig 1A & 1B: Pre-accreditation case of smile make-over with six direct composite veneers showing before and after frontal smile views.

Can you tell us about your Accreditation journey with the American Academy of Cosmetic Dentistry (AACD)?

I was motivated to do something that earned me the capabilities and credentials to be different than any next-door dentist. Soon I became an AACD member and started preparing myself mentally & financially for the daunting journey that was in the offing. The first step was to systematically organize the workflow of photographic documentation of my clinical cases. Photography is the most critical step before onboarding the accreditation process. With guidance from friends and recommendations from AACD resources & mentors, I invested in my first D-SLR camera Nikon D100 which was a gold standard in those times for accreditation documentation. I also bought a dual-point flash Sigma 140-DG.

In the first six months, I got into the groove of the AACD photographic documentation requirements. I then registered for the Annual AACD meeting 2007 in Atlanta USA and appeared for the accreditation written exam. As soon as I cleared the written exam in July 2007, I had a stipulated five years to complete five prescribed clinical case types to be submitted. This appeared to be a long time available but believe me, the time you need to fulfill all passing criteria in the end result of a given case can even take as long as 2 years or more which in itself was a revelation and a big learning process for me. The AACD has a very objective assessment of the esthetic criteria and the variety of cases prescribed evaluates the all-around abilities of any clinician in different areas of esthetic dentistry like direct and indirect restorations, smile design, implant esthetics, and more. A conscious consistent effort, guidance from like-minded friends, AACD mentors, disciplined work, proper case selection, organized clinical execution and long hours of backend time spent at the dental technician’s office led to my ultimate success in passing all stipulated case types by December 2010, about three & a half years after passing the written exam. I am always grateful to my dental technician Danesh Vazifdar for his expertise, unstinted support, and patience in getting impeccable indirect restorative outcomes.  I was only the third Indian dentist to get to the finish line of the AACD accreditation in early 2011. This not only elevated my credibility within the professional circles but also added the weight of a recognized & responsible esthetic dentist in my practice domain.

Fig 2A & 2B: Passed accreditation case type 5 views (Smile Design with six or more direct composite veneers) showing before and after frontal smile views.

How has Aesthetic Dentistry evolved over the last 15 years?

When I began my dental career 20 years ago, esthetic dentistry was more about getting the ultimate cosmetic outcomes at the expense of replacing natural tooth substrate with either direct or indirect restorative materials. The aggressiveness in the removal of natural tooth tissue then was starkly evident in the choice of restorations like wrap-around veneers, full crowns, and fixed bridges. With the biomimetic approach coming to the fore in the last decade or so, we came to realize the importance of preserving natural tooth substrate to the maximum. The significant strides in our ability to bond to multiple tooth substrates as well as many indirect material surfaces like lithium disilicate, zirconia, Bio-HPP, nanoceramics, etc have driven our efforts towards the use of adhesive approaches.

Taking a multi-disciplinary and biomimetic approach to getting to a biologically stable and functionally sound outcome has superseded our conventional treatment planning to transform smiles with aggressive restorative approaches. The other big stride is obviously in the direction of using digital technology to guide our treatment planning and execution. Smile designing using digital tools has been continually getting more accurate &  predictable. One can translate the digital smile design into 3-D printed models for use in subsequent steps of the smile transformation. Today, multi-layered esthetic blocks of a variety of materials from lithium disilicate (eg. e-max CAD, Ivoclar Vivadent) to translucent zirconias (eg. Ceramill Zolid FXML, Aman Girrbach) to hybrid ceramic materials (eg. Vita Enamic, Vita Zahn) are available which are trying to displace traditional ceramic layering and pressing techniques.

Which areas according to you still have scope for improvements?

Digital technology has brought in a plethora of changes within the gamut of dental SOPs and will continue to evolve in leaps and bounds in the years to come. However, in my honest opinion, dentistry is a highly personalized and skill-oriented field where the skill sets, wet hands, and clinician's analytic abilities will continue to remain an integral part of the treatment success, despite all the digital planning protocols. We don’t want dentists to only copy-paste digital solutions but use them creatively and innovatively to transform smiles with a sound scientific approach. There are constant innovations in surgical as well as restorative techniques using digital tools but the scan, plan & execute approach is dependent on the precision of software and hardware that are used. There is no standardization across the globe when it comes to digital workflows and we are left to the mercy of manufacturers' support and training given for a particular software/ hardware. Many of the earlier software systems and versions were close-ended and also dependent on their own hardware for manufacture. My take on this is that we need to make them more standardized, open-ended systems with a simpler user interface to enable ease of adoption for every clinician. Esthetic outcomes of monolithic milled restorations though significantly improved over the years, cannot be compared or matched to the layered glass-ceramic restorations. As of now, digital tools and protocols also add to the overall cost of treatment on the clinical as well as laboratory front and that is one area that will hopefully see a downward trend with the passage of time.

How quickly could you adapt your practice to this change?

I believe that constant renewal of ones’ knowledge and skills is critical to keep us proficient in our field. I have always made it a point to be knowledgeable about the flux of materials and technology that we witness all the time. Although I am a slow adopter of new materials or technology,  I do keep myself informed about new products hitting the markets. I also keep reading up on evidence-based data that gets accumulated around such new products or technology. As a matter of principle, I review my information from time to time and incorporate at least one new technology, tool, or material every year into my practice. We have been using digital technology in areas like guided implant planning, customized abutment and framework designs, CAD-CAM esthetic restorations, digitally printed temporaries, etc. In the time to come, we plan to acquire digital tools like an intra-oral scanner, spectrophotometer, and an in-house 3D printer. The digital disruption that we are currently witnessing will continue to evolve further and each one of us must change our mindsets, skillsets, and toolsets to stay relevant amidst changing times.

Who has been your inspiration in your career?

This is surely a tough one to answer. From the very beginning of my career to date, there have been several people who have inspired me from time to time in different ways. The very first influence who made me change my entire perception of dentistry and practice management skills was Dr. Sandesh Mayekar who raised the bar of esthetic dentistry as a recognized specialty in India. On the academic front, some of my early influencers were AACD speakers & mentors with whom I could interact personally as well as train in honing my skill sets. My biggest inspiration for all my direct restorative skills has indeed evolved from and is attributed to Dr. Newton Fahl Jr. who is a true master in composite artistry. On the indirect restorative front, Dr.Pascal Magne has been a truly great influence who changed my perspective on adhesively bonded restorations and their confluence with biomimetic principles. This brought about a drastic change in the way I began to practice restorative procedures on a day-to-day basis to the extent that fiber posts and full coverage restorations started becoming more extinct in my practice slowly but steadily. A long list of global educators who have incessantly inspired and ignited my mind include  Frank Spear, John Kois, Gerard Chiche, Didier Dietschi, Mauro Fradeani, Roberto Spreafico, Francesca Vailati, Jordi Manauta, and many many more. My very good friend and classmate from my dental school days, Dr. Ali Tunkiwala has always pushed me & inspired me to realize my true potential. Apart from his profound knowledge and credentials he has several talents which inspire me to live a life beyond dentistry. Lastly, one person whom I admire and look up to is Dr. Udatta Kher, who strikes a great balance of his all-around clinical abilities and his academic excellence by way of authoring books, publishing articles & lecturing on national as well as international podiums.

You have also recently been certified by the European Society of Cosmetic Dentistry (ESCD). Can you describe the process and challenges you may have experienced?

I joined ESCD to further my passion for esthetic dentistry at the behest of a good friend Dr. Abby Abraham who is the country chairman for ESCD in India. I was already an accredited member of the AACD as well as IAACD when I took up ESCD membership in 2017. Having done two varied yet successful accreditation processes, I was keen to pursue yet another challenge that keeps my mind intrigued and active. The ECSD offers certification for its active members and the process involves the submission of three clinical cases with a different photographic documentation protocol which is prescribed by them. I had to get into the groove of the ESCD  photographic case documentation criteria, which added a new dimension to my already ingrained protocols. This was a mentor-guided submission process and this only increased my interaction with some highly experienced clinicians from this organization. After passing the cases, we had an opportunity to present one of our best cases with fellow certified members at the annual ESCD congress. Finally, the certification ceremony and the celebration that followed indeed made me feel like a triumphant graduate student. I would encourage every clinician to embark on any such process that can kindle their mind, keep them challenged and enable learning in a true sense.

Fig 3A & 3B: Post-accreditation smile enhancement case with ten direct composite veneers showing before and after frontal smile views.

What newer things do you expect to become the norm in the coming years? What procedures, steps, and materials are on the verge of disappearing, according to you, in the coming years?

The digital revolution is only going to explode in the years to come with artificial intelligence and cloud storage making us more globally connected than ever before. Many analog procedures like wax-ups are already being replaced with digitally designed mock-ups & 3D printed models. Conventional manual-visual shade matching techniques with their inherent drawbacks would be superseded by intra-oral scanners or spectrophotometric color measurement for shade matching. As intraoral scanners become commonplace in dental practices, we will see a southward trend in the usage of conventional impression techniques and materials. Chairside automated end-to-end 3-D printing will steadily increase to carry out many procedures in-house like temporary & interim prostheses, splints, surgical guides, dentures, etc. Guided surgeries will become more prevalent due to precision, minimal invasion, and predictable prosthetic outcomes. Digital facebow and articulators would slowly take over their analog counterparts. The vast improvements in physical & optical properties of milled materials like zirconia, lithium disilicates, and newer polymeric composite materials will wane down the conventional pressing, casting and layering techniques that need more manpower and are time-consuming. Even some of the direct restorative work may get replaced eventually with milled or printed restorative solutions. Adopt and adapt - is going to be the key for all moving forward.

Do you have any advice for the younger clinicians who would like to follow in your footsteps?

I feel that today our profession is flushed with ample resources to augment our learning processes. One can take as many CE courses and training programs as he/she wants with relative ease. However, there are no shortcuts to success unless one implements and puts to practice whatever is learned. The trials and accompanying failures are what teach you more than the knowledge alone. Any challenge that you take up as an accreditation or certification process, brings in a sense of discipline, and direction and draws ones’ focus towards a goal. I would encourage young clinicians to stay away from FOMO (please Google it) on social media and rather focus on challenging themselves all the time, develop a self-critical analytic ability and try raising their bar by constant acquisition and application of knowledge in their practices. As someone has rightly said that “Education turns mirrors into windows”, my advice to all is to keep learning throughout their career span.

Aesthetic dentistry American Academy of Cosmetic Dentistry Cosmetic dentistry Digital dentistry European Society of Cosmetic Dentistry (ESCD)

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