February 2009, Volume 5, Issue 2
Published by AEGIS Communications
Biodontics®: The Next Dental Frontier
Edward F. Rossomando, DDS, PhD, MS
In 1944, during the days of the second world war, J. Robert Oppenheimer, the leader of the Manhattan Project, was beginning to see an end result from his work in Los Alamos, New Mexico. At this midpoint of the 20th century, the Manhattan Project was only one of several scientific successes of the era; another was the discovery of penicillin. With the triumphs of wartime science in mind, Vannevar Bush, director of the Office of Scientific Research and Development, was asked by President Franklin D. Roosevelt to draft a report that would examine the role of science in peacetime. In 1945, Bush’s report, Science: The Endless Frontier, was published. But by that time, Roosevelt had died and Harry Truman was president. While Truman did not act on many of the recommendations in the report, many consider this document to have provided the framework for development of the finest research effort the world has seen to date.1
The Frontier: An American Experience
While perhaps only a coincidence, the use of the word frontier in the title of Bush’s report is surprisingly reminiscent of its use in another equally influential report, Frederic Jackson Turner’s essay The Significance of the Frontier in American History.2 When published in 1893, Turner’s report outlined the definition of “frontier” as a uniquely “American phenomenon,” a definition that continues to resonate through American society. The word “frontier” conjures up images of roll-your-own smokes, cowboys, stampeding cattle, and vast wide-open prairies. The word gathers its own meaning and unifies the various iconographies of the American experience.
The Dental Frontiers
The dental profession has had its frontiers. Dentistry crossed its first frontier in 1840, when the first dental school was opened in Baltimore. The second frontier was crossed in early 1926, with the publication of Gies’ report regarding the state of dental education. In late 1953, following the publication of the structure of DNA, dentistry entered an era of genomic thought, its third frontier. In 2008, dentistry crossed into its next frontier—one in which the genomic theory is fulfilling its promise in the development of biotechnology-based diagnostics and therapeutics. As these new products emerged into the dental marketplace, dentistry entered its fourth frontier. Because this fourth frontier represented not just an evolution, but a revolution in how dentists think about disease and how they practice, this frontier was given a special name—the Biodontics frontier. Biodontics has been defined as the repair, restoration, and replacement of lost tooth structure using bio-based materials of cellular origin.3 It will replace the traditional xenodontic dental practice, which uses nonbiological materials that are foreign to the body.3
This column reviews the history of the three previous frontiers and discusses the issues facing the dental educational system in preparing dental graduates for practice in the Biodontics frontier.
The First Dental Frontier: 1840—The First Dental School
Diseased teeth have been treated for centuries by a variety of “healers.” Until the mid 19th century, however, the education of dentists was by apprenticeship. In 1840, when the first dental school in the world opened in Baltimore, Maryland,4 dentists began the journey into a professional frontier. The first curriculum included subjects such as anatomy, chemistry, and physiology, for a total of about 200 hours of science.5 Through the last half of the 19th century and into the early 20th century the scientific content of the curriculum increased, justified in part by the increase in scientific discoveries.
The Second Dental Frontier: 1926— The Gies Report
In 1926, Gies recommended increasing the number of basic science hours to approximately 500. Dental educators at the then 43 dental schools immediately agreed. One reason for the rapid acceptance was that this increase was accommodated by increasing the number of years to achieve a dental degree from 2 to 3.
There was another reason as well. Given the positive view of science in American culture throughout the 1900s, the dental academic community recognized and agreed with Gies; that to apply scientific findings to dental practice, science courses were an absolute necessity for dental students. Also, dentists—who at home were enjoying music from Edison’s Victrola and converting their gas lights to electric—were eager to introduce the latest technology into their practices not only to provide the best oral healthcare but also to show their colleagues and patients that they had the latest and best. Whether it was a radio, the new flying machine, or racing across the country in Pullman cars and steam engines, Americans—including dentists—realized a new era was unfolding because of science and that an understanding of that science was vital to enjoy these advancements. To have a modern dental office, a scientific education was not only necessary but critical. For example, many dentists of the early 20th century desired to incorporate radiography into their practices, just as physicians were doing, and, therefore, applied pressure on dental schools to add this new technology to the curriculum. In those days, technology transfer was rather slow. X-rays were discovered in 1895 by Wilhelm Roentgen and were used as early as 1896 by C. Edmund Kells for diagnosis.6 However, because training in dental radiology was not introduced into the dental school curriculum until 1918, x-ray machines would not become a fixture in dental practices until the early 1930s.7,8
From 1840 to 1953, first in Europe and then in the United States, scientific knowledge and technologic advances poured from academic, governmental, and industrial laboratories. Many of these technologic advances, including the electric light, the model T automobile, and the airplane, not only had a profound effect on everyday life, but also affected the way Americans viewed science and technology. Dentistry and the dental profession were not immune from these scientific, technologic, and cultural changes. One of the most important advances was the research of W. D. Miller. In 1890, Miller published his seminal work linking microbes to the decay process, thereby disproving the miasma theory of dental disease and extending the germ theory to dental caries.9 In 1898, William Hunter introduced the term oral sepsis to the profession, thereby applying Miller’s work to dentistry and particularly bringing attention to the contamination potential of then current prosthetic procedures.10,11 Throughout the early 1900s, several published findings would finally make explicit the importance of oral infection to the practice of dentistry.12
By 1926, the success of the scientific method in finding causes and treatments for human diseases had been established for both medical and dental diseases. In medicine, the method was applied dramatically and effectively to the etiology of cholera and tuberculosis.13,14 As a result of the application of the scientific method, the germ theory of disease was firmly established, displacing the miasma theory—the theory that diseases were caused by noxious air—and allopathic medicine was able to displace the panoply of faith healers that practiced “medicine” until the early 1900s.15 By 1926, the year the Geis Report was published, dentistry crossed from its first frontier into its second frontier and would remain there until 1953, when it entered its third frontier.
The Third Dental Frontier: 1953—The Structure of DNA
As the century reached its halfway point, a scientific discovery was made that was about to shatter the tranquility and complacency of both the medical and dental professions and usher in the third dental frontier. This discovery, coupled with many more to be made during the remainder of the century, was so disruptive that both professions’ ability to adapt, change, and grow would be severely tested. In 1953, the structure of DNA was published, leading science, society, and dentistry into the genomic era—and for dentistry entry into its third frontier.16 While this discovery produced a significant change in scientific circles, the medical and dental professions remained relatively unchanged. By 2001, however, the force of the discovery of the structure of DNA and the bioscience information accumulated in the intervening 40 years led to the formulation of a genomic theory of diseases—both medical and dental. As this theory gained momentum in the medical community, there were those in the dental community who began to think about applying this new bioscience knowledge to dental diseases. As this idea began to gain acceptance, dentistry entered its next frontier—a frontier characterized by the transition of the biosciences from the laboratory to the marketplace and to their use by the innovator and entrepreneur.
The Fourth Dental Frontier:2008—Biotechnological Diagnostics and Therapeutics
In 2008, the efforts of innovators and entrepreneurs began paying off, and bio-based diagnostics and therapeutics started emerging from the discovery pipeline and entering the marketplace. From these efforts, diagnosis and treatment will shift from a theory of disease based entirely on microbes to one based on the genome and epigenetics.17 Clearly, to have a successful practice in the 21st century, dental graduates will need the intellectual framework to incorporate genomic bio-based products and technologies into their practices. Only if the intellectual framework is incorporated into the dental curriculum will dental schools be able to graduate professionals with adequate exposure to biological science and an understanding of its importance. The Biodontics Educational Program (BEP) is a curriculum that provides this intellectual framework. The BEP provides courses that allow mastery of the scientific progress of the past 10 to 20 years, particularly mastery of areas such as genomics, proteomics, and phenotyping technologies, the microbiome and epigenetics.
Incorporating the BEP into Existing Dental School Curriculum
Currently, dental schools are attempting to deal with the last half-century increase in scientific bio-knowledge but the dental school environment is very different from that in 1926. In 1926, when Gies recommended increasing the number of science courses, dental schools made room by increasing the curriculum from 2 years to 3 years, and then soon after to 4 years. While there was a brief flirtation by some schools with a fifth year, competition from the traditional 4-year schools and profound questions about financing an extra year of dental school quickly ended consideration of this experiment. Unable to expand the curriculum beyond 4 years, dental schools are faced with few options to deal with an already crowded curriculum. One option, as summarized in the following section, is to alter teaching strategies in an effort to better instill basic sciences into the curriculum without changing the amount of curriculum hours.
Using Biotechnology to Teach Bio-Science
Given the constraints on curriculum expansion and faculty reluctance to make hard choices about which content to keep or delete, the most viable option may be to change the format for teaching bioscience. For example, it could be argued that there already is sufficient basic science in the curriculum to build students’ understanding of new bio-based diagnostic and treatment technologies that are soon to emerge from the developmental pipeline. This argument is rarely stated but is apparent from a reading of dental schools’ mission statements. For those dental schools whose mission is to teach xenodontics—a term introduced to refer to the use of metals, plastics, and other materials foreign to the human body for the repair, replacement, and restoration of diseased and missing teeth—it might not be necessary to increase the science hours.3 Indeed, because of the introduction of new equipment such as computer-aided design/computer-aided manufacture (CAD/CAM) technologies and lasers, new products such as composites, and new procedures such as implant placement, an argument can be made that a better use of time would be to ensure mastery of these technologies and products.
In today’s dental education, using the lack of availability of clinical diagnostic or treatment technology as a reason not to teach a subject should come as no surprise. This same argument was used by dental educators in the 1900s. In the absence of a technology for clinical use, the dental professional is often reluctant to endorse the incorporation of science that underlies this technology. Again the parallel between 1900 and 2000 is striking. Historians have noted that it was not until after the availability of the first commercial dental x-ray unit in 1913 that dental radiography became a central diagnostic tool for the dental profession.6 Before 1913, not a single dental school in the United States taught the subject of radiography.6-8 Though physicians had made use of x-rays for many years—a Philadelphia physician had even presented a lecture to that city’s dental society in 1906 entitled, “The Advantages of X-rays in Dentistry”—it would not be until after 1926 and Gies’ report that dental schools would teach radiography courses.18
The fact that bio-based diagnostic and treatment technologies are not on the market should not preclude their introduction to dental students. Introducing innovations into the dental curriculum before the technology based on the innovation reaches the marketplace offers several advantages to learning both the science and clinical treatments. First, if these innovations are introduced within the science curriculum, they can be used as examples of the relevance of science material. Introducing biomimetic tissue engineered from stem cells for the replacement of dental and craniofacial structures can be useful in teaching basic science subjects from histology and embryology to the molecular biology of growth factors.19 Introducing emerging diagnostics that use saliva for the detection of caries risk and periodontal diseases and for various cancers would demonstrate the relevance of topics from immunoassays, molecular biology assays, polymerase chain reaction, and “chip” technology. Lectures that incorporate recent progress on vaccines for dental caries and periodontal diseases would include, by necessity, the science of vaccine biology, immunology, microbiology, and pathology.20-22 Including bio-based dental diagnostic and treatments might be one way to introduce genomic science content without an increase in the number of science hours.
Dentistry has entered the fourth frontier—the Biodontics frontier. Dentistry is leaving the era in which the treatment of dental maladies was based on the germ theory of disease and tip-toeing into the era where the treatment of dental diseases will be based on the genomic theory of disease.
Those who graduated in the 1990s, 1980s, 1970s, and 1960s entered practice inculcated with the germ theory of disease—this theory guided clinical thinking and treatment planning. Now, graduates are faced with a dilemma—they too can intone the liturgy of germ theory, but they are acolytes of the new genomic theory of disease. They have one foot in the third frontier and the other in the Biodontics frontier. The two frontiers could not be more different: they differ in everything from office design and management to products and equipment. New graduates must deal with both frontiers as they make decisions. The Biodontics curriculum has emerged in response to the need for graduates to negotiate and function in both frontiers.
Success of the dental profession is directly tied to dental schools’ success in preparing for the Biodontics frontier. Conquering frontiers has always been something uniquely American. As with past frontiers, the Biodontics frontier stretches before dentists, offering obstacles but also providing opportunities. As with past generations of Americans, the next generation of dental professionals will overcome the obstacles and take advantage of the opportunities. But the next generation cannot do this without help. It is the responsibility for all in the dental enterprise, including those in dental education, the dental industry, and dental practice, to work together to provide a pathway through the next frontier. With the development of the Biodontics curriculum, the pathway has begun.
Dr. Rossomando is the founder and director of the Biodontics® program at the University of Connecticut School of Dental Medicine.
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About the Author
Edward F. Rossomando, DDS, PhD, MS
Professor and Director
Innovation Center for Delivery of Oral Health Care
School of Dental Medicine
University of Connecticut