October 2011, Volume 7, Issue 9
Published by AEGIS Communications
Robert J. Genco, DDS, PhD
This past president of the AADR and IADR shares his thoughts on his research on the connection between oral disease and systemic disorders.
Interview by James B. Bramson, DDS
Inside Dentistry (ID): How did you become interested in dentistry and, more specifically, your various research studies?
Robert J. Genco (RG): When I was in college, I worked in a lab during the summer and became interested in research. A friend of mine who was a periodontist was active in research. I was pre-med at the time, and he said I really ought to think about going into dentistry—it would be easier for me to combine a clinical career with a research career. That is what really led to my going to dental school.
Once there, I was given a wonderful opportunity to work in an immunology laboratory for three years. That experience cemented my interest in research. During that time, I heard a lecture by Fred Karush, who was an immunochemist at the University of Pennsylvania. I was very impressed with him—I applied to work in his laboratory and was accepted. I obtained a PhD with him, and at the same time took clinical training in periodontics with D. Walter Cohen—he developed a combined PhD and periodontal residency for me, for which I am very grateful.
ID: What role had the most influence on you, shaping your perspective on the subjects you wanted to research?
RG: I think the opportunities I had to work in the laboratory as an undergraduate and as a dental student really gave me a good sense of what research was about—the excitement of it. It was difficult with my studies—I worked weekends and after school—but I enjoyed it. I was fortunate to be able to carry out projects that challenged existing dogma regarding autoimmune diseases with Ernst Beutner and Ernest Witebsky, scientists at the cutting edge of this field.
ID: Do you think there’s enough time in the lives of today’s dental students to become involved in research?
RG: There really isn’t, as today we have a more complex, time-consuming curriculum. Even so, I have observed that our students who are really interested can carry out certain research projects. For example, I mentored a dental student who analyzed epidemiologic data. At our dental school, the students get 4 weeks of summer vacation, and the rest of the year is jam-packed with courses. However, he was able to work during the summer as well as weekends during the school year, and did a very nice project in that time. He was motivated to complete the research and present it at an AADR meeting. I’m on the Board of an independent high school program, and it’s the same situation—the high school students are very busy. However, some of the students work with professors at the university, in addition to the academic program at their high school, and they receive an excellent introduction to science, which has helped several to choose a career path in research. I have many colleagues at the university who would spend quality time with these students, but it’s the students and their motivation that really makes the difference.
ID: How would greater exposure to the research environment in the dental school affect students as clinicians?
RG: I think the intellectual training and discipline of research would have a positive effect on their clinical performance. The scientific method can be applied to almost anything—asking critical questions, cautious skepticism, in-depth analysis of the evidence for clinical procedures or drugs—all of these attitudes are important in the clinic.
ID: One of your roles is Vice-Provost and Director of the Office of Science, Technology Transfer and Economic Outreach. That’s a unique role for a dental researcher. What is involved in this program, and how does dentistry benefit from these types of university arrangements?
RG: What I do is really part of the continuum of research, which starts with the basic fundamental view of a problem and the discoveries that may have application to the clinic. The technology transfer process is the end game of research. If research is a continuum of 1–10, basic research is 1–3, and 8–10 is the technology commercialization, the application to benefit society. That is what I do as Vice Provost. It’s very exciting, because I see two to three inventions a week from the university faculty and students in all areas, including dentistry. I believe that my being here has given the dental school added interest in taking what they discover in materials and other areas and applying it to benefit the patient. Many interesting discoveries come from dental schools around the world. Creative dental faculty are often looking to do things in different and better ways. Technology transfer officers in these universities facilitate the development of these products and methods so that they can be used to benefit the patient. Our staff are professionals at protecting intellectual property, developing commercialization pathways, and negotiating licenses to companies that will commercialize the technologies. In addition, we have an incubator facility for assisting university startup companies.
ID: Without giving specifics, how does the university benefit financially?
RG: It’s pretty straightforward. Most universities have a policy based on some very far-reaching federal laws. In 1980, the Bayh-Dole Act gave the university ownership of any research that was completed using federal funding. If someone at the university has a federal grant and makes a discovery, the Bayh-Dole Act specifies that the university where the research was carried out owns the intellectual property and can share in the revenues from this invention. This may seem counterintuitive, but it has worked well leading to development of a multi-billion dollar biotechnology industry in the United States with many useful new drugs and devices that have received FDA approval and are used in daily practice. There are dental schools and universities and faculty inventors that have revenue created from these technology transfer activities, however the main goal of these activities is to bring these discoveries forward to benefit society.
ID: What are your thoughts about how to improve the transfer of new knowledge from the lab bench to chairside?
RG: When I was president of the IADR and the AADR, I thought I knew the answer—just publish the results, and participate in continuing education programs and people will implement the findings. However, I have learned since then, it’s not that easy. It’s very difficult to get people to change what they do, and what they’ve learned and become comfortable with. I’m impressed with new studies of motivation that involve the unconscious, and the more primitive portions of the brain that deal with rewards and fears, and oftentimes are predominant in making decisions. Changing our behavior is the result of the rational and conscious portion of our brain that we listen to when we are told that something works and is supported by studies. The unconscious part of the brain sometimes impedes implementation of the rational knowledge. For example, a recent study showed that one third of patients with diabetes do not follow up on recommended eye examinations, although diabetes-related eye diseases are a major cause of blindness. That’s a research frontier that we need to be involved in. We need to learn better how to change behavior which is critical to transferring knowledge to benefit the patient.
ID: Do dentists typically need role models in the clinic to help validate the research that’s out there?
RG: I think that’s one manifestation of this unconscious behavior. The role models, opinion leaders, provide a wonderful service. As you know, the people doing the research are not often the ones reviewing it in an objective manner. These role models are saying this works in my hands—maybe it does or maybe it doesn’t, but we listen to these people because we intuitively trust them. We listen to them because they’re successful, not necessarily because they’re critically analyzing the science (although some do). Many opinion leaders are very well meaning, but they can perpetuate practices that may or may not be the best from what the evidence suggests. However, changing long-standing practices requires change in behavior which is difficult to achieve even though the science is clear.
ID: A great deal of your research focuses on the connection between oral disease and systemic disorders—specifically diabetes, and the coronary disease and kidney disease associated with diabetes. What are some of the latest research findings on this association?
RG: I think that the strongest oral–systemic association is with periodontal disease and diabetes mellitus. It is clear that diabetes is a major risk factor for periodontal disease; however, it is a two-way street. If a patient with diabetes also has periodontitis, the patient’s glycemic control is often worsened. In addition, the diabetic patient with periodontal disease is at greater risk for heart disease and renal disease than the diabetic patient with healthy periodontal tissues. Many studies have shown that periodontal therapy in patients who have diabetes will also result in improving glycemic control above and beyond that associated with the medical management of diabetes. I think that evidence is quite strong now for the reciprocal association of diabetes and periodontal disease, and we should be proactive in working with our medical colleagues in co-management of patients who suffer from dental disease and also diabetes.
The evidence of periodontal disease associated with HIV is also significant. The World Health Organization is focusing on prevention of periodontal disease as a way to not only promote oral health, but also to benefit systemic health on a global basis. The role of the dentist in the screening and management of the dental patient with HIV/AIDS is well established.
The association of periodontal disease with heart disease is strong as far as the epidemiologic association studies are concerned. However, intervention trials have not been carried out in which periodontal therapy is shown to reduce heart disease, per se. There are intervention trials, however, which show that periodontal therapy in patients with heart disease reduces some of the surrogates of heart disease, such as C-reactive protein.
The evidence associating periodontal disease with low birth rate is strong at the association level. However, while the phase 2 intervention trials have been positive, several phase 3 intervention trials have not shown a protection against adverse pregnancy outcomes as a result of periodontal therapy. Clearly the relationship of periodontal disease to several chronic diseases that are major causes of death, including heart disease and diabetes, compels us to prevent and treat periodontal disease more completely, and to work with our colleagues in the health sciences to help patients modify common risk factors such as smoking and obesity.
ID: Can you comment on the current state of dental research in the United States in terms of money, support, priorities, and interest?
RG: There has been great recent emphasis on involving our medical colleagues. A large percentage of the research budget goes to non-dental schools. Dental professions and dental schools have to become more active in research, because there are many urgent oral health needs that aren’t really being studied at the depth that they should be. Many studies are directed to developing salivary diagnostics, but we’re a long way from their gaining the necessary FDA approval that is required before they can be put into clinical use. I think there has been a shift of emphasis to medically related growth and development, craniofacial biology, and salivary diagnostics, and we probably need to shift back to the core of dental diseases—caries and periodontal disease, and the oral–systemic connections of periodontal diseases and major chronic diseases of man. In doing so, we should be using the latest techniques and most powerful experimental designs to make progress in managing caries and periodontal disease, and common risk factors of periodontal disease and associated chronic diseases.
ID: What is the most significant change that you’ve witnessed in the profession over the past 25 years?
RG: The connection of oral disease and systemic disease, and the sharing of common risk factors among chronic diseases such as periodontal disease, heart disease, and diabetes has been a remarkable paradigm shift in biomedical science. It may be that these associations will bring the medical and dental professions together again in meaningful close associations to benefit patients. For example, with dental treatment and medical treatment for patients with diabetes—they are both so closely related that I think both professions need to be working together to bring out the behavioral changes necessary to control these chronic diseases. In the future, research will help justify dentists’ screening for systemic disease and physicians’ screening for periodontal disease. We will be co-managing patients who have periodontal disease and diabetes and working together with nutritionists—and we will all need to coordinate our efforts around a common cause. It’s the same case with patients with HIV, cardiovascular disease, osteoporosis, and obesity. Expanding our scope beyond the oral cavity in a reasonable fashion by engaging with the medical community will have a very significant influence on dentistry, and marked benefits to the patient’s oral and overall health. At the same time, we have these wonderful preventive, restorative, cosmetic, and implant procedures that will keep getting better, and we will continue to pay attention to these to improve oral and dental health of our patients.
ID: As a member of the IOM’s National Academy of the Sciences, which is populated by very few dentists, can you comment on how the NAS views dental disease these days in light of the research? Do they see medicine and dentistry coming closer together?
RG: I think so—there was a recent report that tried to address that. However, the recent reports still deal with dentistry as separate from medicine. It’s well known that about 60% of Americans go to the dentist once every year or two. Dentistry is a potential point of contact with the health care system that is underutilized. I don’t think that is adequately addressed by the national academies. The issues that come to the national academies about dentistry include manpower, the fate of the dental schools, and role of the federal government in oral care. These are important, but there are many other burning issues including the delivery of oral healthcare services and access to care; the role of universities in dental education; funding of oral healthcare, especially for the 40% of the population that doesn’t have access to private dental offices; and the funding and priority areas of biomedical research related to oral health.
There is a proportionately lower number of dentists in the IOM than physicians, and I don’t think that we have much chance of increasing that number. There are many questions that aren’t being dealt with by organized dentistry or by the national academies, but have great impact on oral health, and we need to deal with them. We need an organization to take hold of these and other issues that are highly important to our patients’ oral and general health and to us. I think we realize that an unbiased, independent, and respected body should be in charge of addressing these issues in a concise fashion on a regular basis, developing strategies for implementation of recommendations. Perhaps we need an existing organization to take on this function, or a new organization may be needed to adequately address these large and important policy issues concerning oral and general health.
ID: If you could change one thing in dentistry in the United States, what would that be?
RG: If I could convince everybody about the importance of integrating oral care with basic healthcare, that would be wonderful for the patient and both professions. We have an epidemic of obesity and diabetes, and periodontal disease and caries are among the most common infections of man. As dentists, we are reasonably good at focusing on health behaviors. We often convince people to practice good oral hygiene and visit the dentist regularly, and I think that we can help the medical profession with our common patients, those with diabetes and heart disease, by helping moderate common risk factors. Most of the chronic diseases, such as heart disease and diabetes, are really diseases that often can be prevented by changing lifestyle. Perhaps we can help our medical colleagues at this difficult task of helping people help themselves by adopting healthy lifestyles. This might have a tremendous effect on the overall health of the population.
About Dr. Genco
Robert J. Genco, DDS, PhD, is Distinguished Professor of Oral Biology, Microbiology, and Immunology at the School of Dental Medicine and School of Medicine and Biological Sciences at the State University of New York at Buffalo. He also serves as Vice Provost for the university’s Office of Science, Technology Transfer, and Economic Outreach, which he helped to establish. Genco is past president of the American Association for Dental Research and the International Association for Dental Research, and was awarded the Gold Medal for Excellence in Research by the American Dental Association.