July/August 2009, Volume 5, Issue 7
Published by AEGIS Communications
What to Watch for in 2020
Merging of information. The application of artificial intelligence-type programs in dentistry. A revolution in the way dentists practice. These are among the transitions and changes that Claudio Levato believes will take place between now and the year 2020 to help shape the future of dentistry.
“The dentist is going to be looking at more computer screens and more data,” Levato predicts. “By 2020, I think we’ll have more tasks to delegate to auxiliary staff, such as routine procedures.”
Within the broader oral healthcare profession, there have already been significant strides made in remineralization, and Levato says this will be a major contributing factor in clinicians’ abilities to treat disease at its early stages and, therefore, actually prevent expensive restorative procedures. “I think the future is extremely promising,” Levato says.
Artificial IntelligenceLevato is hoping that dentistry makes another quantum leap and begins using artificial intelligence. This will require bringing software to its next level, whereby decision-making capabilities are designed into the system.
“So, when dentists do their initial examination, they’ll put in all this diagnostic information, which can be delegatable. This includes x-rays, intraoral photos, measurements, charting existing conditions, the patient’s medical history, and the patient’s habits,” Levato says. “Then the software compiles these parameters and helps determine a treatment plan and a differential diagnosis for what needs to be done for the patient.”
Dentists will be able to take evidence-based dentistry to another dimension that involves standards, Levato says. If someone presents with A, B, and C, has certain risk factors, and has a certain lifestyle, artificial intelligence software would help develop the best procedure for the dentist to provide that would offer the greatest longevity and best results, he suggests.
Barriers for Acid Wear/ErosionConsidering the impact that acid erosion has on the majority of the population (ie, prevalence studies suggest that acid erosion/tooth wear is very widespread), David Bartlett says that the biggest challenge with erosion and tooth wear is developing new materials that can provide some sort of barrier to acidic foods and drinks. Early work suggests that fluoride may help, but in the future Bartlett suspects that additives to toothpastes may have a more specific protective action (eg, a polymer barrier).
“This would be much better than using dentist-delivered products that can only be applied periodically, unlike patient-delivered products that could be applied daily,” Bartlett says. “Other areas for research will be matching the impact of products/interventions to the progression of acid erosion and see if they have a beneficial effect.”
Obsolescence of Physiochemical ImpressionsFarman says it’s important to consider what will go into obsolescence in dentistry by 2020. He believes that physical, chemical impression materials will become obsolete in the next 10 to 15 years.
“The reason they’re not obsolete at the moment is that the resolution we have with CBCT is not adequate to entirely replace the impression tray,” Farman believes. “However, there are some attempts at this point in time at using photographic scans to create models, such as in orthodontics (eg, Invisalign). ”
Lee Culp, on the other hand, believes that all dentists should be looking at some type of a digital impressioning system at this point, or at least starting to gain information about them. Digital impressions are the hot topic, but because there’s still a great deal of confusion in the marketplace about them, dentists have been slow to adopt the technology, he says.
“There are currently four companies that offer digital impression acquisition units, and by 2020, I think the majority of impression materials will be gone. You’re going to see models and stones go the way of the past,” Culp predicts. “This technology is getting better and better, as well as easier to use. I think it’s something that dentists should become familiar with because I think that one of the major technological changes of the next 10 years will be the disappearance of impression materials and the move to digital impressions.”
Bioengineering / Biological TreatmentsAllan G. Farman notes that today’s cutting-edge research is not necessarily cutting because it’s not using handpieces and burs. Rather, it involves bioengineering, using perhaps stem cells to grow replacement teeth, and from there developing a naturally occurring implant.
“In the future we may see a greater move toward getting the teeth to actually restore themselves by simulating normal biological methods, such as the deployment of extra dentin as a seal against the spread of dental caries in adults,” Farman speculates.
According to Frederick A. Rueggeberg, with respect to biology, it seems technology is being driven toward directing a specific reaction in the host. Thus, concepts associated with the current use of implants containing BMPs or other bio-active factors to induce a localized biological reaction will be applied elsewhere to more predictably re-grow missing bone structure of edentulous ridges and lost crestal bone in periodontal disease, he says. The futuristic “restorative materials” would then be used as carriers for such substances, Rueggeberg says.
Personalized DentistryAccording to Isabel Garcia, using information and data from a patient’s level of gene expression to select a medication, provide individual treatment, or start a prevention regimen, is where dentistry is headed in terms of personalized care. In the future, such an approach will enable dentists to provide patients with much less of the generalized, one-size-fits-all care that’s administered today, and more tailored interventions that rely on genetic information and other data specific to the individual, she says.
“There are a couple of factors that I think will drive that transition to personalized dentistry. One is the growth of evidence-based dentistry, such as from the research supported by the NIDCR—like its large-scale dental practice-based research networks,” Garcia says. “As the evidence begins to accrue, dentists will have information just a few computer clicks away to better classify their patient and tailor treatment to their specific oral needs.”
The other factor that will drive the transition to more personalized dentistry is the rise of biology-based dentistry, Garcia says. In the future, dentists will rely on a range of diagnostic and treatment tools that rapidly and efficiently process a patient’s biological information, from genes to protein, she says. Although such resources are being used now, Garcia believes the trend will continue.
Prevention of Third Molar DevelopmentResearch taking place today may affect standard practice in terms of how clinicians address overcrowding—specifically when it comes to removing (or rather preventing the development of) third molars. There have been experiments that have demonstrated that by applying heat to the tooth bud inside the jaw before it develops,11,12 it is possible to destroy the third-molar tooth bud.
“Maybe in the future dentistry will see that type of technology used, rather than the very painful approach to oral surgery at the age of about 20 while studying for exams in university,” Farman suggests. “At the most inopportune time is when the third molars tend to come through and be uncomfortable. If we could find a way of preventing them before they develop, that may not be a bad thing.”
Remineralization of Tooth Structures“Controlled dentin and enamel remineralization can be expected to be highly advanced in the future,” Rueggeberg predicts. “Literature currently suggests that we can remineralize dentin, not in chunks and globs as is currently clinically done, but in formation of microcrystals, the same size and location as are present in healthy tooth structure.”
These advances are still in the developmental stage and are not yet commercial realities, he says. Perhaps future “restorative materials” will merely be temporary “bandages” protecting underlying substances that, over time, will slowly remineralize decayed tooth structure and, eventually, lead to the intraoral development of an intact, functioning tooth once again, instead of replacing missing tooth structure with synthetic substitutes, Rueggeberg speculates.
Stem Cells to Grow Replacement Teeth“Beyond rapid technology and reduced costs for genetic testing to determine relative risk, we also have blended genetics with stem cell biology,” says Harold Slavkin. “This merger is providing fuel to advance tissue engineering, such as BMPs and stem cells for bone regeneration; pulp-derived stem cells to design and fabricate roots of teeth with associated periodontal ligaments connecting synthetic root to adjacent alveolar bone; and many other types of tissue engineering (eg, mucosa, salivary glands, cartilage, muscle, nerve, etc). ”
RoboticsRueggeberg says that the next logical step in CAD/CAM restorative processes is the actual use of microprocessor-controlled robotic devices to prepare teeth in vivo. Then, using digital information recorded from the preparation sequences performed, the 3D dimensions of the prepared tooth, as well as the optical impression of its environment (ie, the neighboring and opposing occlusion) can be sent to a chairside milling device that immediately prepares the restoration without impressions, models, or laboratory processing, he suggests.
Farman shares a similar vision. At the moment, he says dentistry is still basically in the era of Michelangelo, “to a large extent chiseling away at the teeth, albeit with high-speed handpieces, but free hand. Dentists are artists.”
In the future, dentists are going to be architects rather than artists, Farman predicts. They’re going to be designing restorations using CAD programs in computers. At some point they’ll move toward biological treatments. Then, there will be the use of robots that can more readily remove the necessary tooth structure more precisely and maybe on multiple teeth at the same time, either using mechanical methods or perhaps even some refined laser techniques for preparing the tooth, he suggests.
“These robotic devices presumably also will be able to take impressions by using optical scanning methods (ie, as opposed to physiochemically), with integration of the individual images that are then produced,” Farman continues on. Then, using transfer of those light-based images, dentists will be able to send the impression to the laboratory (or in-house facility) for fabrication of the restoration.”