The idealistic strategy is akin to gerostomatology’s restorative strategy (Fejérdy, Nagy, and Orosz 2007). Following this strategy means conceptualizing an ideal, textbook-based morphology of the craniofacial complex and a function adhering to perfect gnathological standards. These ideals may result from a populace’s average, or they may even differ from it, as orthodontically ideal occlusion described by Angle being the exception rather than the norm (Artun 2002). In this case reaching the preferred morphological outcome is the aim, even after a reasonable function is attained and the functional benefits of further interventions are non-existent or marginal, for example by removing clinical sign-free and symptom-free impacted teeth or replacing second molars of a patient with an otherwise functional occlusion, as exemplified in gerostomatology’s restorative strategy (Fejérdy, Nagy, and Orosz 2007). Aesthetic advancement inevitably follows morphological rehabilitation, however additional procedures are not adopted for further aesthetic improvement in this strategy. Thus, function ranks higher than aesthetics. Preserving tooth structure is as moderately important as aesthetics, hence an idealistic treatment plan would permit extracting teeth with less than mediocre prognosis to adequately replace them. To pursue this strategy, a complex treatment plan needs to be proposed with numerous visits, followed by a regular follow-up aiming preventive care.

The disadvantage of this strategy may be the overtreatment of the patient, where the risks of the medical intervention outweigh the benefits, therefore the well-intentioned intervention results in violating the principal of nonmaleficence. Hence in practice a nearly idealistic treatment plan, which raises standards to the highest achievable goal without overtreatment is an ethically acceptable treatment plan and should be presented to the patient, given there are no restraints in accomplishing it. Hereon the patient’s own set of values determine whether they prefer an extensive morphological restoration in multiple visits to the dental office, even if not all sessions improve oral function significantly.

This strategy could be described as a reduced version of the idealistic strategy, in which it is deprived of its idealistic core. Hence it does not demand morphological restoration but rather focuses on clinical signs or symptoms of impaired oral function, restoring the impaired function, and seeking to maintain the achieved state through regular follow-ups. Morphological restoration and preserving one’s dental tissues are as necessary in this strategy as they align with oral function, and the prominence of aesthetics also depends on its role in the patient’s social and psychological health. It is related to the aforementioned rationalizing strategy in gerostomatology (Fejérdy, Nagy and Orosz 2007), where the maximal benefit is meant to be attained with the least number of medical interventions. The theoretical groundwork distinguishes these strategies, as the rationalizing strategy puts greater emphasis on reducing the number of sessions.

The challenge of this strategy is determining the exact goal of the treatment, as oral function is a concept heavily subjected to each patient’s individual terms of well-being. Eventually this strategy does not adopt a textbook-based definition of oral function but tailors it to the patient’s needs bearing the fundamental principles of beneficence and nonmaleficence in mind. A functionalist treatment plan is ethically acceptable for autonomous patients whose own set of values point to sessions limited to restoring function. Likewise, it is also acceptable for patients whose financial, physical, or mental state or other factors compromise their ability to pay more visits to the dentist’s office.

Following this strategy, the primary aim of dentistry is preserving one’s dental and oral tissues. This can take effect in choosing minimally invasive or microinvasive conservative interventions in treating carious teeth, preferring prostheses which do not require tooth preparation, and attempting periodontic or endodontic treatment for teeth with questionable or lower than questionable prognosis. In this strategy aesthetics rank low in the value hierarchy, and while oral health is a capital value, the intactness of sufficiently functional structures is ranked over maximal function. The management of periodontitis and endodontic treatments demand multiple sessions (Moreira, et al. 2017; Kwon, Lamster, and Levin 2021), and the extraction of the tooth is postponed as far as possible, thus analogously to the idealistic strategy, employing the preserving strategy necessitates numerous visits.

Even though this is an ethically acceptable strategy in most cases if it corresponds to the patient’s own set of values, the shortcoming of this strategy lies in the shortage of human resources, since this strategy frequently requires involving periodontist and endodontist specialists (Barnes, Patel, and Mannocci 2010; Pandya 2019).

This strategy ranks autonomy a paramount value, usually intertwined with aesthetics. In effect medical interventions are conducted in a professional setting, however the goals of wish-fulfilling procedures disregard maintaining and improving the patient’s health and oral function (Witter, et al. 2020). In this strategy the dentist’s expertise may be submitted to the patient’s own set of values, making the dentist an agent of the patient (Ozar, Sokol, and Patthoff 2018).

In spite of its antagonistic position to other treatment strategies, which each rank certain aspects of oral health ahead of patient autonomy, overlaps in the actual treatment plans may occur even in the case of wish-fulling dentistry. The reason for this is health being defined as biopsychosocial well-being (Larsen 2022), and that oral aesthetics contributes to psychosocial well-being (Kershaw, Newton and Williams 2008; Eli, Bar-Tal and I. Kostovetzki 2001; Feng, Newton and Robinson 2001). Such homology in treatment plans necessarily occur if the impairment is both physical and aesthetic, for example in rehabilitating edentulous patients (Allen and McMillan 2003), although the emphases of the treatment plans may differ. Discord among the wish-fulfilling strategy and other strategies becomes apparent to a greater extent if the cosmetic treatment is not restorative and it is performed on functional or semi-functional structures.

A non-exhaustive list of cosmetic dental interventions ranked from least to most invasive, hence from no loss to the complete loss of dental tissue is as follows: bonding dental jewellery on the tooth’s surface, vital tooth bleaching, preparation for veneers, preparation for solo crowns, and tooth extraction for aesthetic restoration. Analogy in ethical considerations in the latter example can be drawn to other medical interventions, in which autonomous patients desire psychosocial benefit despite physical impairment. However, the ethical acceptance of this broad group of procedures varies, as sex-reassignment surgery is commonly estimated to be beneficial to the patient despite causing infertility, while limb-amputation in Body Integrity Identity Disorder is generally not approved of (Kovács 2009). Further on, besides the wish-fulfilling strategy, the functionalist strategy would also allow impairment of dental hard tissue as long as it is negligible compared to the gains in psychosocial well-being.

Additionally, a utilitarian argument can be made for a shared employment of the wish-fulfilling strategy with other strategies, as granting the patient’s desires upholds the relationship with the patient (Asscher, Bolt, and Schermer 2012). Thus, it may be a tool to gain the patient’s compliance for subsequent medically indicated interventions.

Literature describes a dichotomy between professionalism and commercialism in dentistry, in which wish-fulfilling dentistry would incorporate commercialism (Ozar, Sokol, and Patthoff 2018). However, commerce is not necessarily incompatible with professionalism, and medicine has nearly always been practiced within a marketplace. The ethical employment of this strategy requires the dentist to conform to an extent to the patient’s own set of values, making the dentist an agent of the patient, rather than becoming an actor thriving to fulfil their own interests (Ozar, Sokol, and Patthoff 2018). Furthermore, the author believes that in the occasions, when the practitioner does submit to a treatment plan without medical indication, the fundamental ethical criteria is to minimize risk, for example supporting excellent oral hygiene associated with cosmetic interventions impairing hard dental tissue.

This strategy focuses on exclusively treating conditions resulting in acute impairment in function, such as acute pain, for example as a result of the exacerbation of chronic inflammation. Usually, an acute treatment strategy seeks to definitively eliminate the cause of the impairment in one session by invasive intervention, or if this is not feasible, it seeks to provide medically indicated curative care in the given session. This strategy resembles gerostomatology’s postponing strategy due to the lack of action unless action becomes inevitable (Fejérdy, Nagy, and Orosz 2007).

Despite limiting dental care to acute care cannot typically be the aim of a dental practitioner, notable exceptions exist. These exceptions can be linked to external factors or factors related to the patient. External factors include any form of lack of resources or capacity to perform non acute care, as it is intentionally the case in dental emergency facilities. In such scenarios after the acute intervention is completed, the patient must be referred to another practitioner or recalled to another appointment, where these restraints are eliminated. Factors related to the patient include but are not limited to the following: any patient practicing their autonomy to refuse further dental care, the patient’s treatment posing acute risk to the personnel’s health, e.g., acute contagious infections, however the patient in this example should be recalled to a later appointment, patients with a life-threatening general condition (Status IV. patients according to the American Society Anaesthesiologists’ Physical Status Classification System (Horváth et al. 2021), end-of-life patients, where the stress caused by extensive dental care may exceed its benefit, neglectable oral function, as in comatose patients. In these cases, the benefit and risk of dental care should be evaluated and strategies requiring less intervention should be employed.

Similarly to the functionalist and acute treatment strategy, this strategy also focuses on impaired function. However contrary to them, it is only concerned about impaired function that the patient perceives as such, and as its prime goal is providing non invasive care, it is not interested in eliminating the underlying cause of the impairment. Ultimately this strategy can also be compared to gerostomatology’s postponing strategy (Fejérdy, Nagy, and Orosz 2007), although it does not aim to reduce the number of visits, only their invasiveness. The set of circumstances where this treatment strategy is ethically appropriate largely overlaps with the external and patient-related circumstances described at the acute treatment strategy, provided that an acute condition is not present, the maleficence caused even by the acute treatment outweighs the benefit, or an autonomous patient refuses any invasive treatment. In addition to the aforementioned situations, carrying out symptom management instead of invasive dental care is also ethical, if the dentist lacks expertise to perform the adequate intervention, and refers the patient to another professional.