July/August 2009, Volume 5, Issue 7
Published by AEGIS Communications
Allison M. DiMatteo, BA, MPS
As dentistry looks ahead to 2020, it's natural to try and excitedly forecast the conditions and trends that will shape the profession and the face of oral healthcare overall. In some instances, advancements and discoveries in one area may come to bear on another, helping to broaden our understanding or use and application of that innovation or scientific discipline in the context of oral healthcare.
Consider genetics, for instance. Harold Slavkin, DDS, dean of the University of Southern California School of Dentistry, recalls that a few years ago, two famous scientists—Dr. Craig Venter and Dr. James Watson—paid millions of dollars to have their genomes sequenced, likely becoming the first two people to have “personalized human genomes” produced. Aspects of Venter’s genome were even published in 2008 in the science section of the New York Times, Slavkin said.
“Incredibly, and in tandem, a number of new personalized human genetics companies for profit were launched in 2008, such as 23 and Me and another called Navigenics. The innovation is that these new companies charged less than $1,000 for a genome-wide ‘risk assessment’ for individuals through a mail-order approach,” Slavkin explains. “It is now estimated that a complete genome will be available by 2012 for $1,000 per person. Dentistry can better position itself to learn when and how to use this emerging technology as a ‘value added’ service to keenly interested patients and their families.”
The trend of increasing affordability of the different genetic approaches to the diagnosis and treatment of disease is something important to note, believes Isabel Garcia, DDS, MPH, deputy director of the National Institute of Dental and Craniofacial Research (NIDCR). As costs come down, this type of approach will become progressively more mainstream and, along the way, will have implications for dentistry, she suggests.
In the early 1990s, the cost to do DNA sequencing was significantly high. By the year 2003, the cost for doing that had dropped tremendously, Garcia observes. Just like the prices of home computers, flat-screen TVs, and other technologies have dropped considerably since they first arrived in the marketplace, the cost of sequencing DNA in the years ahead will become incredibly affordable, she says.
“The NIDCR is already doing some genome-wide association studies of dental caries and oral clefting,” Garcia says. “We definitely look forward to more studies being supported in the years ahead, and this trend really brings the implications for genome scans into the dental office.”
If it seems too futuristic or far-fetched, remember where implants were not all that long ago. Then consider the concept of such technologies as those involved with digital dentistry and digital impression taking. According to Lee Culp, CDT, vice president of dental technologies for D4D Technologies, these two innovative areas are in much the same place that implants were 10 or 12 years ago.
“With implants today, people are getting comfortable with them, and they’re not just for the surgeons. General practitioners are looking at them,” Culp says. “We’re getting to that point in digital dentistry now.”
However, others have observed the adoption of new diagnostic technologies at a fast clip. Allan G. Farman, BDS, PhD, MBA, DSc, professor of radiology and imaging science at the University of Louisville School of Dentistry and president-elect of the American Academy of Oral and Maxillofacial Radiology, notes that over the past 10 years, the most important change to take place in diagnostics is the move from two-dimensional radiographic imaging to three-dimensional cone beam computed tomography (CBCT). In the future, dentistry will be looking at an entirely different group of technologies than at the moment, since three-dimensional imaging technology will be available in small and inexpensive enough units for everybody to be able to use them, he predicts.
But with an ability to provide patients with more accurate and precise diagnoses, what awaits dentists in the future in terms of treatment options? Frederick A. Rueggeberg, DDS, MS, professor and section director of Dental Materials in the Department of Oral Rehabilitation at the Medical College of Georgia School of Dentistry, says that despite tremendous advances in dentists’ ability to “bond” to tooth structures, the durability and predictability of such treatment has been less than desired. This has led to the constant marketing of supposedly new and advanced products that all operate on the same premise, he says.
“I foresee the day when biology and synthetic restorative dentistry are intermingled,” explains Rueggeberg. “Here, a ‘molecule’ fabricated for bonding to tooth tissues will do so with one end attaching in a biological manner and the other end using a chemical mechanism to a polymerizable matrix composite.”
This month, Inside Dentistry narrows our telescope into the future and focuses on four core areas that will affect dentistry and oral healthcare: diagnostics, technology, genetics, and material science. Our interviewees offer a glimpse of the trends taking place today in each of these areas that will come to bear on what happens tomorrow to enhance treatment efficiency and improve clinical outcomes in the dental practice.
Diagnosis of oral diseases in the future likely will have a greater emphasis on biology in order to deliver more personalized care, predicts Garcia. As examples, she identifies three areas under investigation and development todaythat will impact professional practices of tomorrow.
Salivary diagnostics has received a great deal of attention, explains Garcia. Salivary diagnostic devices are under development, and some of the first studies are underway to identify and, importantly, validate biomarkers in saliva that are linked to a range of diseases.
“There are many advantages to salivary-based tests compared to the usual blood-based clinical tests. They’re safe, acceptable, and can be collected in a noninvasive way compared to either blood or urine, and actually self-collection is possible,” Garcia elaborates. “I think this is one area that will drive much of the biology-based care in the future.”
In the area of oral cancer screenings, Garcia says that diagnostic tools are beginning to emerge that really read the molecular signatures of cells from suspicious oral lesions. As a result, this research is now refining the definitions of the molecular make-up associated with all phases of tumor development, she says.
“Researchers are then tapping into that molecular information in order to develop prognostic information by looking at certain mutations in a particular gene of oral cancer patients and evaluating whether those mutations are actually linked with overall survival,” Garcia explains. “Scientists are using the molecular information, or the signatures, from those tumor cells to be able to have prognostic information about the patient.”
For identifying the causes of inflammation in periodontal disease, the NIDCR is supporting research to define the tell-tale patterns of gene expression within the biofilm of certain bacteria that infect the oral mucosa, Garcia says. By taking that research and coalescing it with modern immunology, cell, and molecular biology, dentists will be able to more precisely identify the causes of the inflammation in periodontal disease and then target the treatment to alleviate the disease, she says. They also will be able to more precisely monitor the oral conditions during follow-up care.
In dentistry, technology has applications for various aspects of diagnosis, treatment, and restoration. Culp suggests that scanning and laser technologies will be introduced in the future, leading to a clinical arena where everything will be digital, from caries detection to periodontal probing. He sees these applications being performed with a laser, noninvasively.
Other technology predictions for 2020 envision computer-based technologies being intertwined and integral components of each of these three facets of oral care if in no other way than by facilitating communication and information sharing among interested professionals.
The Drive for CBCTs
“Right now you can’t pick up a journal or go to a lecture without somebody talking about 3D dentistry in one form or another, and I think what’s capturing dentists’ attention, in particular, are CBCTs,”1 believes Claudio M. Levato, DDS, a private practitioner in Bloomingdale, IL. “It’s been something unique because it’s a very large ticket item. The first CBCT was FDA-approved in 2001 and now, 8 years later, we have about 20 different companies that have CT scans for dentistry. It’s kind of strange that such a high-ticket item is attracting so much competition.”
Levato believes the driving force for this and the reason that CBCTs are taking dentistry by storm is the increase in implant placements. The number of implant companies introducing new products also is phenomenal, he says.
“CBCTs give you the ability to plan your cases very thoroughly. They allow you to actually, in some cases, plan and design your prosthesis so that you can perform your surgery and insert the prosthesis at the same time, on the same date,” Levato explains. “This is really revolutionary and exciting.”
Software Innovations for Management & Collaboration
“The software is really the whole foundation that allows us to go ahead and use the application,” Levato says. “When we buy a piece of technology, we don’t give the software a second guess, but that’s really the strength of the whole system.”
Levato says dramatic changes to practice management software now enable greater facilitation of appointment confirmation and general communication with the patient base (eg, surveys, billings, online bill paying, viewing of appointments, marketing). More importantly, however, he says practice management software has made a quantum leap into the new millennium by allowing dentists to access their data from anywhere and send it to anybody else that needs to review it—whether from their iPhone or home computer. Today, if dentists do something interesting, they can post it online right away, and there are even some on YouTube, he remarks.
“These trends are coming at us from so many different directions,” Levato remarks. “Five years ago, none of this was being done. Practice management and other software applications are really, really powerful.”
Technology Translates to the Future of Digital Dentistry
“I started working with CAD/CAM in 1990, and at that time, the technology was in its infancy,” Levato recalls. “The computer infrastructure was inadequate to allow us to do what we’re doing today. Now, the process is much simpler, so much more accurate, and with a minimal learning curve. What’s more, these are delegatable applications, which means that the dentist can be more productive.”
What exists today for the digital dentistry world as far as technology and instrumentation goes includes the afore-mentioned CT scan machines, but also digital impression-taking devices that capture an optical impression, rather than requiring the dentist to use traditional materials, Levato explains. That impression is sent electronically to a laboratory, where the model is then milled and subsequently forwarded to the technician who makes whatever restoration the dentist prescribes. The use of this technology is only likely to increase, not decrease, in the years to come.
“You also have two products that will allow dentists to make single restorations in their offices in one visit. CEREC has been around for almost 20 years, and the E4D System is finally on the market,” Levato says, adding to the list of digital dentistry armamentarium. “Clinically, these also are 3D applications.”
As the collective dental profession heads toward 2020, Culp sees laboratory technicians using such 3D, digital dentistry technologies to design their models and restorations at the same time. Those pieces will come from a centralized milling or design center, he says.
“So, technicians will design everything on their computers, and then there will be industrial processing centers that will send the copings, crowns, models, basically everything to the technician to finalize. You’re going to see a lot of that,” Culp predicts. “Essentially, I think we’re going to see, especially in laboratories, a move away from in-lab milling and a return to industrial milling. However, we’ll all be interconnected—the dentist, technician, and manufacturer.”
Additionally, while many today may see CAD/CAM technology for dentistry as merely an output device that simply makes teeth, Culp truly believes that in the future, CAD/CAM technology will facilitate communication between the doctor and technician. In fact, he sees the dentist and laboratory technician diagnosing, treatment planning, and designing cases together three-dimensionally using CAD/CAM and communication technology, with perhaps even the patient being involved.
“What’s more, as we move in and start marrying CBCTs and intraoral scanning, there are going to be some incredible opportunities to get the resolution we need to accurately create restorations when we marry those two types of scans together,” Culp says.
According to Slavkin, most of us think of genes asdiscrete “beads” on a string of DNA, with most of the string being of little consequence. Gregor Mendel focused on the phenotypes of genes in plants that code forshape, color, texture, and size of peas.
“We have come a long way since Mendel. Today, we think in terms of human genetic variations that can be caused or represented by single nucleotide polymorphisms (A, adenine, T, thymidine, C, cytosine and G, guanosine) at a frequency of 1 or 2 per 1 million nucleotides,” Slavkin explains. “We also are beginning to understand that all human diseases and disorders are ‘genetic’ and most reflect multiple gene-gene and gene-environment interactions. A new mathematics has evolved to help to understand and express the relative burden of risk factor genes in an individual person.”
Of particular relevance to dentistry, Slavkin comments that in the last decade there has been enormous progress in identifying genes for specific dental tissues such as enamel, dentin, cementum, periodontal ligament, alveolar bone, oral mucosa, etc. In addition, Mendelian-inherited genetic diseases have been identified and characterized on the basis of gene networks. And, as discussed earlier by Garcia, saliva as an informative body fluid is being used to discover genetic biomarkers for health and disease. When it comes to genetics, Slavkin says there has literally been a renaissance of discovery.
“All educated people, including all oral health professionals, need to know and learn how to use ‘personalized human genetics,’” Slavkin emphasizes. “We have an extraordinary opportunity in our dental profession to learn, expand our competencies, and to better serve all at the same time.”
With advances made in understanding the world on a “nano-scale,” Rueggeberg can foresee where dental manufacturers will be able to formulate restorative materials on a near molecular level, providing properties similar tothe natural tooth structure that’s missing. Such knowledge would allow for optimizing the mechanical, physical, and optical properties of restorative materials that, perhaps, would finally approach those of the natural dentition, he says.
However, Rueggeberg cautions that the “ultimate” direct restorative material has yet to be developed. This material would be one that requires absolutely no mixing of components and is merely placed in a minimal cavity preparation.
“The ‘ultimate’ product would provide instant and strong self-adhesion to tooth structure, be able to be placed in bulk, and be able to be forced to set upon command via some mechanism,” Rueggeberg elaborates. “The resulting restoration would be durable and have smart ‘optical properties’ that act to automatically acquire the correct color characteristics of surrounding natural tooth structure.”
Rueggeberg also advises that dental professionals are becoming ever aware of the potential of minute amounts of contaminants in our civilization that arise from sources we had previously either ignored or thought were benign. He says a prime example of this is the issue surrounding estrogenic-like compounds leaching from resin-based dental restorative materials, such as pthalates and bisphenol-A.2,3,4,5 Efforts will probably be made to either ensure use of raw materials with no traces of contaminates, or different polymerization schemes using totally different chemistry where such compounds will not be present, Rueggeberg predicts.
Indirect Restorative Materials & How They’ll Be Processed
According to Culp, the future development of indirect restorative materials and the technology with which they’ll be processed go hand in hand. A long-time advocate of CAD/CAM digital dentistry, Culp believes the biggest thing onthe horizon will be the ability to fabricate such restorations faster, easier, and quicker—and this will involve the ability to actually make a full-contour tooth.
“The systems that will actually make full-contour teeth; recognize contacts, margins, and occlusions; and then make a restoration out of a metal-free material are the most exciting,” Culp says. “That’s what dentistry will be in the future, and that’s what will affect all-ceramic materials.”
However, Culp says the most exciting material development for CAD/CAM restorations centers around lithium disilicate glass ceramic, a material that has been available for almost 15 years and has undergone university testing both in vitro and in vivo. This material allows laboratory technicians to design and mill full-contour restorations, then just stain and glaze them, he says. Further, lithium disilicate restorations demonstrate high strength that enables clinicians to seat them with either conventional cementation or self-etching primer bonding, Culp adds.
“I think the number of these types of restorations will increase as more labs get into doing CAD/CAM work,” Culp says. “If we’re predicting the future, I see a lot less technicians for socioeconomic and aging reasons. But as computers get more popular and technicians are able to accomplish more work on them, they’ll be able to mill restorations out of these new materials and just stain and glaze.”
Not wanting to take anything away from the artistry and creativity of technicians, Culp admits that he foresees a big change in the way laboratories will make restorations. In particular, he says there always will be times when a coping will have to be made and a very talented technician will be needed to layer up multiple layers of porcelain to achieve perfect esthetics. However, Culp says he sees that increasingly going away, especially for restorations in the posterior region where the esthetic demands aren’t that high.
Composites & Dentifrices to Combat Tooth Wear
According to David Bartlett, professor and head of the department of prosthodontics at King’s College London Dental Institute, the recent interest in acid erosion by dental researchers in the United States has particular relevance to dentists here because erosion affects many teeth, posing restorative challenges and possibly leading to the need for multiple crowns or other aggressive therapies. Therefore, the cost to restore teeth damaged by erosion is significantly higher than for teeth affected by dental caries (can affect single teeth, unless rampant caries arewidespread).
Looking into the future, Bartlett says the aspiration is to minimize the effect of any wear in order to keep teeth looking good longer. New toothpastes may help prevent acid erosion by hardening the tooth surfaces, making them more resistant to acids, he says.6,7,8
“In time, other products may also form a barrier over the tooth to protect it further from the effects of acids, but also from tooth to tooth wear (attrition) and abrasion (eg, tooth brushing),”9,10 Bartlett explains. “In some patients the amount of acid erosion and wear is much more severe and can compromise the longevity of the tooth. For this type of situation, dentists need to restore the shape and function of the tooth with restorative materials.”
Bartlett says that at the present time, these materials include composite fillings or crowns. New development in these materials may occur over the next decades and may match the physical properties of teeth better than those available today, he speculates.
The future potential of this proud profession is endless. However, seizing any opportunities requires individuals knowledgeable enoughabout the possibilities to drive the profession forward.
“The oral health professions have a challenge. Should required education include a thorough understanding of modern human genetics coupled with testing and genetic counseling?” asks Slavkin about dental education heading into the future. “Should CE programs and DVDs be developed to upgrade practitioners’ understanding and competence in the area of gene testing? From my vantage point, this might be a ‘use it or lose it’ situation.”
“I think it’s important to recognize that genetics will just be one new component in dentistry in the future. Our Institute has excellent work underway in many different areas—tissue engineering, imaging, developmental biology, and clinical research, to name a few,” Garcia points out about the NIDCR. “But we also have to be cognizant of oral health disparities and continue to tackle those problems. These sophisticated tools of the future will help best when they can reach the most people.”
To Farman, the big advancement to come will involve removing the dentist’s hands from the mouth and converting them from being an artisan to an architect. “That is my main philosophical way of looking at how the future is likely to progress,” Farman says. “In the interim, obviously we’ll need to develop better dental materials for restorations, but hopefully, in the long run, we’ll be looking at more natural treatments.”
Interestingly, as we look ahead to what technology and science can offer, Rueggeberg reminds us of the most essential component of dental practice.
“With all these advances, however, dentistry still remains totally unique among all health professions, as the clinical practice will (and MUST) still include a significant person-to-person dynamic interaction of trust, and care,” Rueggeberg asserts. “No materials, techniques, or breakthroughs will ever replace the unique human touch, which was ‘invented’ long ago, and really needs no further improvement.”
1. Levato CM, FarmanAG, Chenin DL, Scarfe WC. Cone-beam computedtomography: a clinician’s perspective. Inside Dentistry.2009;5(5):66-73.
2. Lewis JB, Rueggeberg FA, Lapp CA, et al. Identification and characterization of estrogen-like components in commercial resin-based dental restorative materials. Clin Oral Investig. 1999;3(3):107-113.
3. Arenholt-Bindslev D, Breinholt V, Preiss A, Schmaiz G. Time-related bisphenol-A content and estrogenic activity in saliva samples collected in relation to placement of fissure sealants. Clin Oral Investig. 1999 Sep; 3(3):120-5.
4. Sasaki N, Okuda K, Kato T, et al. Salivary bisphenol-A levels detected by ELISA after restoration with composite resin. J Mater Sci Mater Med. 2005;16(4):297-300.
5. Koi PJ, Kilislioglu A, Zhou M, et al. Analysis of the degradation of a model dental composite. J Dent Res. 2008;87(7):661-665.
6. Bartlett DW, Smith BG, Wilson RF. Comparison of the effect of fluoride and non-fluoride toothpaste on tooth wear in vitro and the influence of enamel fluoride concentration and hardness of enamel. Br Dent J. 1994;176:346-348.
7. Wiegand A, Attin T. Influence of fluoride on the prevention of erosive lesions—a review. Oral Health Prev Dent. 2003;1:245-253.
8. Zero DT, Hara AT, Kelly SA, et al. Evaluation of a desensitizing test dentrifice using an in situ erosion remineralization model. J Clin Dent. 2006;17:112-116.
9. Piekarz C, Ranjitkar S, Hunt D, McIntyre J. An in vitro assessment of the role of Tooth Mousse in preventing wine erosion. Aust Dent J. 2008;53:22-25.
10. Sundaram G, Watson T, Bartlett D. clinical measurement of palatal tooth wear following coating by a resin sealing system. Oper Dent. 2007;32:539-543.
11. Silvestri AR Jr, Mirkov MG, Connolly RJ. Prevention of third molar tooth development in neonate rate with a long pulse diode laser. Lasers Surg Med. 2004;35(5):385-391.
12. Silvestri AR Jr, Mirkov MG, Connolly RJ. Prevention of third molar development in dog with long pulse diode laser: a preliminary report. Lasers Surg Med. 2007; 39(8):674-677.