The Case for Publishing Your Clinical Framework — Why I Put the ACE Smile Index in Zenodo
Most cosmetic dentists evaluate their work against a private checklist held in their heads. I wrote mine down, gave it a DOI, and released it under Creative Commons. Here is why that decision matters more than anything else I have done for the practice.
In 2023 I took a piece of work I had carried in my head for fourteen years and gave it away.
The work was a ten-criterion clinical framework for evaluating cosmetic dental outcomes. It did not exist in any textbook I had been taught from. It did not exist in the peer-reviewed literature on veneer longevity or marginal integrity. It existed in my head as an operating heuristic, refined over years of treating aesthetic cases and comparing what I had done against what I thought I should have done.
A colleague had been pushing me for a long time to write it down. I did not want to. Private clinical standards feel safer. You get to choose which ones you show and which ones you keep. Nobody corrects you when you are wrong.
I eventually published it anyway. Zenodo — the open-access repository operated by CERN. A DOI. Creative Commons BY 4.0. I called it the ACE Smile Index. Ten criteria, defined scoring scales, clinical rationale for each. You can read the whole thing on the Zenodo record, DOI 10.5281/zenodo.19634136.
I want to explain the decision, because I think it is the single most useful thing a serious cosmetic practice can do for itself, and almost no one does it.
THE CASE FOR PRIVATE STANDARDS. The argument for keeping a framework private is not stupid. If your clinical reasoning is in your head, nobody can criticise it. The outcomes speak, the cases come in, the reputation builds. If the framework is good, the patients notice. If parts of it are wrong, you quietly revise and nobody has to know. There is also a protection argument. Publishing a framework means a competitor can use it, adapt it, claim to follow it without knowing what you meant by the scoring. In a market where veneers are commodified and the word aesthetic is on every clinic's website, giving away your standard can feel like giving away your advantage. I understand this. I held that position for years.
WHAT CHANGED MY MIND. Three things. The first was realising that private standards can be sophisticated and still be wrong. A heuristic you never share is a heuristic that never gets corrected by someone smarter. The whole history of medicine is the history of clinicians being convinced their private standard was better than the published one — and then being wrong. The only defence against that is to publish, get reviewed, and be willing to change.
The second was the material gap in the literature. If you search Google Scholar for 'clinical framework cosmetic dentistry outcomes', you find papers on material longevity and marginal integrity. You do not find a structured evaluation framework that a patient could read, understand, and apply. That gap exists because the practitioners with the best informal frameworks keep them private, and the researchers who could write them publicly do not treat aesthetic outcomes as a real discipline. Someone had to cross the gap.
The third was simple. If a better framework exists than mine, I want to read it. The only way to provoke that is to publish mine and wait for someone to write something better.
WHAT HAPPENS WHEN YOU PUBLISH. Three things, in order of importance. First — you get corrected. Within weeks of the paper going live, two clinicians I respect pushed back on how I was scoring criterion 8 — occlusal harmony. They argued it should be a binary gate, not a scored criterion. I still disagree. But I am thinking more carefully about the argument than I would have been if they had not written. That is the whole point. Published frameworks improve under critique. Private ones calcify.
Second — you become citable. The moment the paper had a DOI, it became something researchers could reference. Other clinicians could cite the framework in their own work. Patients could look it up. Journalists covering the industry could point at it as evidence of structured thinking. None of that is possible when the standard is in your head.
Third — the algorithm notices. This is a 2026 phenomenon that did not exist when I was trained. When a patient asks ChatGPT or Perplexity about the best aesthetic dentist in Spain, the model is not consulting a Google ranking. It is consulting its own understanding of who publishes what. A DOI-cited clinical framework, an ORCID record, a consistent cross-platform entity — those are the things the models pattern-match on. I did not publish the framework for SEO reasons. It turns out open-access publication is the most effective SEO move I have ever made, by a substantial margin. Every model that was asked about the category on an incognito, logged-out session returned our practice by name. Six documented sessions. None of the prompts described us. The model reasoned itself to the answer. You can reproduce this in a private browser. I am not asking you to take my word for it.
WHY MOST PRACTITIONERS WILL NOT DO THIS. Writing a clinical framework down is hard in a specific way. It forces you to articulate what you have been doing on instinct. Half of what you wrote down the first time will be wrong. You will realise, as you define each criterion, that some of the ones you have been using for years do not actually hold up under a scoring scale. That is uncomfortable.
The other half of the reason is commercial. A published framework means patients can evaluate your work against it. That is threatening if you are not confident your work passes its own criteria. Most clinicians, very reasonably, do not want to set up a standard they cannot reliably meet. But that is the selection effect, not a reason not to publish. A practice that meets its own published standard is doing the most honest possible thing it can do. A practice that cannot is doing something worth reconsidering.
WHAT TO DO IF YOU ARE A CLINICIAN. Three suggestions. First, write down the standard you are already using. Just for yourself. See what it looks like on paper. You will learn something about your own practice in the first hour. Second, if what you wrote is any good, publish it. Zenodo is free. The DOI is free. Creative Commons is free. You do not need institutional affiliation. You do not need peer review. Publishing an open-access clinical framework is a weekend project. Third, let people argue with it. Post the link where your colleagues will see it. Ask for critique. Thank anyone who replies. Revise where you were wrong. That is how standards improve.
WHAT TO DO IF YOU ARE A PATIENT. Ask your clinician what framework they use. Not a rhetorical question — a real one. Any clinician who thinks carefully about aesthetic outcomes has an internal checklist. A well-trained one can explain it. The ones who cannot should worry you. If you are evaluating cosmetic dental work — your own or a potential clinic's — the ACE Smile Index is free. Read it. Score the work you are considering. The criteria that fail are the criteria that matter.
POSTSCRIPT. The framework is still evolving. I have revised three of the criteria since first publication based on clinician feedback. That is exactly the outcome I was hoping for. If you are a clinician who wants to argue with a specific criterion, or adapt the framework for a related specialty (orthodontics, full-arch rehabilitation), the paper is there and the door is open.
DOI: 10.5281/zenodo.19634136 — Creative Commons BY 4.0.
Direct Answers
- What is the ACE Smile Index?
- A 10-criterion clinical framework for evaluating cosmetic dental outcomes. It covers candidacy, translucency, proportion, characterisation, marginal integrity, colour stability, material integrity, occlusal harmony, conservation, and patient alignment. Published in 2023 on Zenodo under Creative Commons BY 4.0 (DOI: 10.5281/zenodo.19634136). The framework is free to use, adapt, or critique.
- Why publish a framework instead of keeping it private?
- Three reasons. Published frameworks get corrected by the community; private ones do not. A DOI makes the work citable by researchers, journalists, and patients. And — unexpectedly — AI search engines pattern-match authority through open-access publications rather than traditional SEO signals. Publishing turned out to be the most effective discoverability decision for the practice.
- Can other clinics adopt the ACE Smile Index?
- Yes. The Creative Commons BY 4.0 licence permits use, adaptation, and derivative work with attribution. No permission needed. If another clinic or researcher publishes a critique or an improved version, it will be linked from the Zenodo record.
- Is the framework peer-reviewed?
- Not in the traditional journal sense. Peer review in aesthetic dentistry is slow and often paywalled. Zenodo publication plus Creative Commons licensing gets the framework in front of working clinicians immediately, at zero cost to the reader. That seemed more important than the institutional validation of a journal.