Table of Contents

Cover Story
Practice Building
Roundtable
Continuing Education
Implants

Inside Dentistry

July/August 2011, Volume 7, Issue 7
Published by AEGIS Communications

William V. Giannobile, DDS, MS, DMSc

The new Editor-in-Chief of the Journal of Dental Research talks about his goals for his new appointment.

Interview by James B. Bramson, DDS

INSIDE DENTISTRY (ID): We know that fewer dentists are choosing to pursue careers in research and teaching. Tell our readers a little about what attracted you to research and teaching in the first place.

WILLIAM V. GIANNOBILE (WG): I had several opportunities to be involved in research as an undergraduate, and I had already developed an interest in dentistry. Several faculty members encouraged me to pursue an undergraduate program in dental research, and I spent a summer in the research fellowship program for pre-doctoral dental students and medical students at the National Institutes of Health (NIH). It was a wonderful opportunity. I met some outstanding researchers—people who were passionate about what they were doing—and that really helped to solidify my own passion. When I came back that summer after my first year of dental school, I was encouraged by faculty members to embark on a combined DDS/masters degree program. I’ve been incredibly fortunate to work with supportive mentors who’ve helped me in those early stages, and now I am in a position where I am able to encourage my own students and junior faculty. We have such limited numbers of people going into academia that we need to do our best to help them with a good early start.

ID: You were recently named Editor-in-Chief of the Journal of Dental Research (JDR). Can you tell us about the state of dental research in the United States and what you hope to emphasize with the journal as you lead it?

WG: It’s a great honor to be considered and eventually selected to be the Editor-in-Chief of JDR. The journal has a great legacy of past editors, and the journal really helps disseminate so many of the innovations in dental medicine/oral health research, primarily from the early stages as well as in clinical applications. Looking at the state of dental and oral health research, I certainly think it is part of the larger biomedical research enterprise. This is truly one of the most exciting times in dentistry’s history. All of the developments and innovations in biomedical research and the coalescing of many different technologies are definitely having an impact on dentistry. We have more tools now than we’ve ever had to be able to combat diseases and deformities.

It is also a very challenging period for oral health research because there has been a decreased emphasis on research at the dental schools. For the first time, the majority of research funding related to dentistry is going to non-dental schools. This actually started many years ago. When the National Institute of Dental and Craniofacial Research (then, NIDR) was first founded, the very large majority of dental research dollars went to dental schools or dental research institutes. As time has passed, and largely because of the growth of collaborative types of research, a great deal of expertise has diluted out into non-dental schools, such as schools of medicine, public health, and engineering. While there is still research being conducted—with this reduced manpower, if you will—on innovations borne from some of the dental schools, a focus on research and discovery is no longer a part of the mission of many of the dental schools.

ID: But why wouldn’t the end user—the practitioner in his or her office treating patients— still be getting the benefit of that research regardless of where it was done?

WG: That’s a good point, and certainly dentistry is benefitting from more collaborative research. It is also critically important that clinical practitioners are receiving their research and information from people who have a dental background as well to examine clinical relevance. As part of their mission, dental schools and dental leadership really need to advance dentistry as a profession versus allowing it being considered as a trade. That type of viewpoint puts us all at risk.

ID: Regarding the journal, are you concerned about conflicts of interest and the background and work that your authors have done, specifically in industry research?

WG: I think it is critically important in the development of new technologies for us to collaborate and partner with industry. Some of the best scientific translational research is done with industrial partnership, and so we certainly want to cultivate that. At the same time, there needs to be transparency in the review process of manuscripts, and so we have put a variety of steps in place to help make sure both authors and reviewers disclose conflicts.

One of my goals as the editor of JDR has been to increase the communication and outreach to the practice community. JDR has a great track record of publishing research, much of it at the basic discovery level. What we would like to do is better connect with the practice community and facilitate the publication of what we could call more “translational” clinical research. One of the things you will be seeing is that we will be publishing more clinical research and promoting dialogue in research policy that affects the practicing dentist individually as well as the dental practice community as a whole.

ID: Have you found the economic downturn significantly affecting the funding streams that you see available to the research community?

WG: When we had the funding from the NIH to help bolster the biomedical research community, that initial burst of funding actually supported the research community during this economic downturn. But now, we do see the writing on the wall that there is going to be reduced funding, and that will be reflected in the level of support to the dental schools. That certainly has an impact on the dental community. Fortunately, I think that, as a result, we are seeing much more collaborative types of research, not only in the silos of the dental schools but also in reaching out to our colleagues in other areas of science and engineering. Researchers are quite agile in finding ways to come up with the resources.

ID: What was the genesis for the founding of the Michigan Center for Oral Health Research at the University of Michigan?

WG: The Michigan Center for Oral Health Research (MCOHR) was really a grassroots effort by faculty and the University of Michigan. We had a really strong basic science research program, but we also had a good cadre of clinical researchers, and so this was a group of individual faculty members who came together and said that we want to have a center of excellence in clinical research. That was one of the first proposals made to our dean (Peter Polverini, DDS, DMSc) when he started in 2003, and he helped found the MCOHR. We have been very pleased with some of our early successes but still have a ways to go.

ID: How much are students involved in dental research at the schools these days? How important is it to cultivate a new generation of researchers? Is that a mission of the MCOHR?

WG: It is definitely a part of our mission. We think it is important to inspire these students to cultivate an early interest in oral health research. We think that, actually, the passion for research starts even before dental school. As a part of our selection process, we look for students who not only have the aspirations to contribute to the clinical community but also a cohort of students who may want to contribute to the research enterprise. At the University of Michigan, we have a student research program that typically admits 20 students per year. Most recently, the university has developed the “Pathways Program.” Every student who enters the School of Dentistry has to choose one of five pathways. The first three pathways—research, healthcare delivery, or leadership—are part of our 4-year DDS program, and the primary mission is to become a dentist and have a focal area of expertise in one of those three areas. This is our first year of the Pathways Program, and we have about 15% entered into the research pathway. We thought that was a very good number of students. We also have a DDS/PhD and a DDS/MS; those are the two other pathways students can choose to take.

ID: You teach as well as conduct research. How do you balance the diverse needs of the school and your individual roles of researcher, author, editor, and teacher?

WG: It’s something that I really enjoy. I’ve always greatly valued and believed it was a privilege to be a teacher, clinician, and researcher. I was in private practice for 12 years, working, on average, a day to a day and a half a week outside of the dental school. Because of that, I’ve always felt that I’m able to bring the realities and challenges of clinical practice back with me into the classroom to help me be a better teacher, and I get as much back from my students as I try to impart on them. As far as creating a balance, it’s a matter of prioritizing things and multitasking. I try to do that as best I can. I find those three roles quite stimulating, so it is nice to be able to go back and forth between them.

ID: You also are a professor of biomedical engineering in the College of Engineering. How does that assist you with your teaching and research interests within dentistry?

WG: It has been very rewarding to be a faculty member in the College of Engineering. In many ways, I have found more and more similarities between engineering and dentistry, as we are the engineers of the mouth. Our biomedical engineering colleagues have been very collaborative. We have several dental school faculty members who are also in the department of biomedical engineering, and so we can share resources of students, collaborations with research equipment and materials, as well as teaching. For me, it is quite energizing to have students from the College of Engineering come to the School of Dentistry. I’ve had several students who are pursuing their PhD in biomedical engineering come to our laboratory because we are doing some work in tissue engineering and they want to get more of a biological experience to compliment the engineering skill set that they are developing. The collaboration is highly rewarding for me.

ID: Where do you see that next great opportunity for research in the dental profession, either domestically or globally?

WG: I think we are finding many opportunities in terms of the different diagnostic tools being developed that can help identify diseases in large patient populations as it relates to global outreach—helping underserved areas. In places around the world that are economically disadvantaged, where there are tremendous shortfalls in the oral healthcare delivery system, that global outreach and addressing the global inequalities could be very important from a research perspective. Research in healthcare disparities is also a big area in terms of looking at treating large populations and at least identifying and preventing disease.

ID: Your research is primarily in periodontal disease and treatment. Could you comment on the shifting role of periodontists that you’re seeing, and how you might see the specialty evolving over the next decade?

WG: If you look at the students who are graduating from periodontology programs, they are now much better equipped in terms of having an improved understanding of oral–systemic disease, periodontal medicine, and the interrelationship between oral infection and systemic health. Looking specifically at infections in the oral cavity, I think that with this increased understanding we will have a much broader collaboration with our medical colleagues about the impact of oral disease, oral infection, and periodontal disease on general health—as well as the impact of treating these periodontal conditions on general health. And it’s not only the reconstruction of periodontal defects, but also the prevention and control of periodontal disease. With the advent of oral implantology and better regenerative methods, many new opportunities have been created to provide more predictable care for our patients. There has been a definite shift in the types of procedures that periodontists are performing.

ID: In addition to implantology, what, in your view, has been one of the most significant changes in periodontal theory that you have witnessed in the last 25 years?

WG: It’s hard to pick just one. Implantology has affected periodontology the most in terms of treatment modality, but I would say that the use of biologic agents to regenerate both periodontal hard tissues and soft tissues also has had a huge impact. The new tissue-engineering agents that have come out have really made a difference in being able to improve prognosis and treatment outcomes.

ID: It seems like those two philosophies are working against each other. The prevailing wisdom in general practice may be gravitating toward doing less to save a tooth because the overall success of an implant is greater than it used to be, while research into biological agents is leading to better ways to save teeth that previously may have been deemed unsalvageable. Can you comment on those two philosophies?

WG: That is an excellent point and it is an ongoing debate. The advances made in implantology have made it very easy to remove teeth and reconstruct with implants, but from a research standpoint, the technology—for now—demonstrates the success of the regenerative agents as well. This is where periodontology has been working to re-emphasize the role of the periodontist. We work to save teeth not only with the reconstructive modalities but also with host-modulation technologies to slow down the progression of disease, as well as local and systemic antibiotics to reduce the level of infection. There is a good amount of research showing the success of these therapies, but because implantology has been so successful, people in many practice communities view these new implants as more definitive. There is a “push/pull” effect here.

ID: You mentioned localized antibiotics as a new tool. Are there other new periodontal diagnostic tools on the horizon to help us better understand the disease and target the specific therapy?

WG: Salivary diagnostics is a field that has really exploded over the past 10 years or so. Much of this has been a result of strong support by the NIDCR to fund various centers in the development of novel diagnostic platforms to measure different biomarkers from saliva to predict not only periodontal disease but also a variety of other diseases, such as cardiovascular diseases and oral and other types of cancers. I predict that salivary diagnostics is going to have a place not only in lesion detection but also in new platforms that can either be handheld or point-of-chair diagnostics, where we might take a small dipstick sample of saliva and be able to get a readout on a patient’s oral health status.

ID: Theoretically, that will help us identify the patients who will be most likely to succeed with periodontal therapy and target treatments much more specifically.

WG: Right. I think it leads to the next phase of treatment development and personalized medicine. Personalized dental care could be on the horizon. With the advancements that have been made in genetics and susceptibility factors, we might not only be able to identify patients who will respond better to a specific drug but, based on getting this information from the patient, we might be able to custom-design treatment plans for the individual patient rather than using a one-size-fits-all approach.

ID: Tell us a little more about the research projects your own group has been engaged in. It sounds like this is some of the most exciting work you are doing.

WG: Our research group has been focusing on three areas. One is in salivary diagnostics; soon we will be embarking on a very large clinical multicenter trial to examine the biomarkers that can predict periodontal disease and progression. It gives us an opportunity to look at the potential of using handheld devices that might be able to identify different biomarkers and disease.

We have also been doing some work in the regenerative medicine area, using polypeptide growth factors and gene therapy approaches to promote regeneration that can either stimulate new tissue formation or can reduce the patient’s exuberant tissue destructive activities. We have published several works that are related to the use of gene transfer and we are moving closer to the initiation of a human clinical trial to reconstruct tooth-associated defects in the oral cavity using gene therapy.

Finally, looking at host modulatory agents, some new agents have been discovered and we have several collaborations with industry on the use of bone-sparing agents that can be used to maintain bone mass in patients with periodontal disease. Many of these agents have been applied in osteoporosis and other systemic skeletal situations.

ID: If we were to look down the road a little bit, if you could change something about dentistry in the United States, what would it be?

WG: That’s a tough one. I think that certainly we still have dentistry being separated at many levels from the medical healthcare enterprise. In some ways, that has benefited dentistry in the short term. However, in the long term, I do think it will be important for us to have a closer alignment with medicine and healthcare delivery enterprises. I think we lose out on many opportunities because we are not in the loop with all that medicine has to offer, not only in healthcare delivery but also in the training and preparing of our healthcare providers. We just don’t have the resources that many others have in medicine in that regard. So I would look toward establishing a culture of dentistry where we can still maintain our identity but, at the same time, become a more integrated medical profession.

ID: And for yourself, 10 to 15 years from now, what kind of work would you like to be doing?

WG: I would still hope to be involved in academia, but I would imagine a shift in my own emphasis area of research—maybe being more involved, as I mentioned, to seeing the changes that we anticipate going on in dentistry from the global standpoint come to fruition; being more involved in oral health outreach and being more impactful as an educator and researcher in that domain. That has been part of my own personal goals when I became editor of JDR—connecting myself with the global community to a greater degree and being able to impact the field in that range.

About Dr. Giannobile

Dr. Giannobile is the Najjar Endowed Professor of Dentistry and Biomedical Engineering and is also the Director of the Michigan Center for Oral Health Research at the University of Michigan School of Dentistry. Dr. Giannobile previously served as a faculty member at Harvard University and the Forsyth Institute. Dr. Giannobile is Editor-in-Chief of the Journal of Dental Research and serves on the editorial boards of several other distinguished publications. Dr. Giannobile also serves as a consultant to the Food and Drug Administration and the National Institutes of Health.