March 2012, Volume 8, Issue 3
Published by AEGIS Communications
Kenneth S. Kornman, DDS, PhD
The founder of Interleukin Genetics, who developed the first genetic test for periodontal disease susceptibility, focuses on the future.
Inside Dentistry(ID): As a renowned periodontist, what inspired you to launch Interleukin Genetics, Inc., in 1986, and how it has contributed to improvements in health?
KENNETH KORNMAN (KK): As a research scientist and a clinician, I was involved in academic research studying both microbiology and immuno-inflammatory responses relative to periodontal disease. While collaborating with some colleagues in the arthritis area, we discussed the similarities between arthritis and periodontal disease and wondered why people differed so dramatically in terms of their susceptibility and clinical expression of these conditions. Because I had an academic background in econometric modeling, we started building computer models to at least begin to better understand what the factors might be that influenced clinical expression of the two diseases. We observed that there was a behavior in the model suggesting that genetic influences could have a significant impact on inflammatory responses. Our subsequent search for information led us to the work of Sir Gordon Duff at the University of Sheffield in the United Kingdom, who had just made the first discoveries of genetic variations relative to inflammatory diseases. We then partnered with the University of Sheffield to conduct genetic studies of periodontitis and licensed some of that technology from the University. We subsequently learned that these genetic factors had broad applications to cardiovascular disease and other diseases in which genetic effects on inflammation is a major contributing factor.
The first product we developed was the periodontal PST® Genetic Susceptibility Test, which was really our first effort to understand how genetics might influence some of the diseases. Since then, we have also developed tests for heart health, weight control, and osteoarthritis. However, we are continuing to develop technology for periodontal disease. Our hope is that these genetic tests can contribute to improvements in health by identifying a propensity, or some probability of risk in the future. The real value for this type of risk test is to focus not on completely healthy people, but on those with early signs of disease or mild periodontitis, and identify those likely to become problematic cases before they become disaster cases.
ID: Once a patient has been determined by these tests to be at risk for periodontal disease, how should he/she be managed by the dental office?
KK: In the general dentist environment, such tests offer the opportunity to examine risk-factor information among patients with minimal periodontitis. This would start with an assessment of the major risk factors that are well documented. Are they smokers? Do they have a history of diabetes? If genetic information is available, are they positive for the IL-1 genetic factor? Do they have any other chronic diseases, for example, rheumatoid arthritis? If the answer is yes to any of those questions—and especially if the answer is yes to two or more—we know those people are at a substantially greater risk of having problems—including severe generalized periodontitis—as well as a less predictable response to conventional therapy. It should, therefore, be automatic to place these patients in a different category to be treated differently. We need to educate them as to their risk factors, and then focus on the two dimensions of the disease that we can modify. First, we need to be more aggressive in bacterial control in those individuals. Second, we need to deal with how the body responds to the bacterial challenge, which calls for more intensive monitoring and, in some situations, the use of host-modulating agents to help control the disease.
ID: How does this fit in with evidence-based medicine, health plans, and third-party payers?
KK: The solutions for healthcare in the future will demand that there be some evidence basis for how we treat patients and how we’re compensated for treating patients. While there is a wealth of information about disease risk and prevention of the major chronic diseases of aging, little of this information has been applied. However, insurance companies are beginning to fully appreciate how this information may influence the structure of plans for the coverage of preventive care and periodontal therapy.
The challenge in dentistry, of course, is that we do not have the large funding mechanisms needed to support definitive evidence-based studies for many of the procedures and products in dentistry. Organized dentistry can play an important role in establishing guidelines based on what we know today while we’re waiting for additional evidence. If clinicians have to make routine patient decisions, we should make a great effort to provide guidance based on the best available information we have at the time. It may not be perfect, but it will be better than asking each individual practitioner to interpret the evidence for themselves.
ID: What are the greatest challenges facing the marketplace, and is the dental sector really any different from any of the other health areas?
KK: I think the dental sector is very different from other areas of healthcare, primarily because of the size of the market; the potential rewards to companies for developing products in other areas is much higher than in dentistry. This makes it a challenge to secure venture capital, which is risk-averse in general, but especially so now relative to dentistry because most new dental technologies have just not been compatible with investors’ financial return expectations.
However, there is an interesting sideline to that, which is that some of the drugs that are developed primarily for use in medicine may in fact be effectively applied to dentistry as a secondary indication. I believe that is one of the factors likely to shape development of new therapeutics and diagnostics in dentistry. Of course, dentistry still offers excellent business opportunities for those involved in the development of certain types of devices, such as implants, and will probably continue to be a profitable market for certain devices based on technology involved throughout healthcare.
ID: Would you say dentists are well prepared during their education both to create and adopt innovations and new technologies?
KK: I think that’s a fascinating question in terms of the way we practice and how we relate to innovation. First of all, most dentists practice either as sole practitioners or in very small groups, which automatically limits some communication that may stimulate innovation. But I also think the education system has not had a history of training dentists either to develop or use some of the more innovative technologies, whether they be diagnostic tools, risk assessment tools, new therapeutic tools, or new biologic approaches.
It is unfortunate that only a handful of dental schools seem to recognize that, in many respects, dental students today are more diverse than they were 20 years ago—with diverse backgrounds, interests, and career goals. Those few institutions have begun developing programs offering dental students exposure to and training in different areas that may be important in terms of future healthcare, including science and research, the business side of developing products, and the economics and planning of healthcare delivery.
In recognition of the diversity of the students and the reality of the complex future of healthcare delivery, more dental schools should offer their students exposure to opportunities in these areas, so they can self-select based on those opportunities.
ID: How can we better translate new discoveries and innovations into everyday dental practice?
KK: We have a real dilemma in terms of how we translate some fantastic science—for example, the connection between periodontal disease and systemic disease—into practical application on a widespread basis throughout medicine and dentistry. It is often the case in medicine that a general profit motive attached to the discovery will drive development and commercialization. However, most of the dental-related discoveries do not translate well and, under the best of circumstances, they take many years before they are applied in ways that people can benefit. Once again, from my perspective, we are challenged by the economic issues of both funding the kind of research projects required to move this into translation, and also having the long-term perspective that is not yet typical of dental projects. For example, the evidence for some role for periodontitis in cardiovascular disease is very strong based on epidemiologic data; there are multiple potential mechanisms to explain that, but ultimately, this information will not become accepted in medicine nor translated into practical application without an intervention study demonstrating that cardiovascular events can be reduced by treating periodontal disease. The funding for such a study is challenging.
That said, there are several journals that have taken leadership roles in helping to translate new discoveries into practical clinical use, including the New England Journal of Medicine. In addition, the American Academy of Periodontology recently launched a new journal focused on the translation of knowledge and converting it into very practical clinical applications.
Beyond that, I really look to the dental schools and to certain components of organized dentistry to begin creating models for translation—not in the typical continuing education courses, but in a manner that links practitioners more directly to new knowledge, and most importantly, how to use that new knowledge.
ID: As the editor-in-chief of the Journal of Periodontology, what’s your view on the state of periodontal science and practice?
KK: There is a tremendous amount of research in periodontology being conducted now throughout the world. With that said, I believe that the United States, to a great extent, still has the greatest depth of innovation and research progress in many areas of dentistry. From reviewing not only manuscripts submitted, but those accepted and ultimately published in the dental field—particularly the periodontal field—I believe the United States is still very strong and continues to lead the specialty to a great extent in terms of research. While there are outstanding investigators and clinicians throughout Europe, their groups are not as large as those found at some of the US institutions. In addition, the United States has benefitted more than Europe from many years of government funding in terms of research.
ID: What would personalized care mean for dentistry as we know it today?
KK: I think it offers the opportunity to commit to a broad movement in personalized medicine in general. In my opinion, this was best described by the well-known scientist Leroy Hood, who sees the future of healthcare as “the four Ps”—personalized, predictive, preventive, and participatory. In dentistry, this can play out very specifically in severe periodontal disease, which affects between 8% and 15% of adults. Among this group, 20% to 25% of the treated patients do not respond predictably to treatment—they continue to show progression, with further tooth loss despite a standard of care in periodontal treatment.
What this means relative to the four Ps is that this is a patient population whose diseases require specialized treatment. We know now we can divide patients into many different categories based on different molecular and biochemical markers and then successfully treat groups previously viewed as untreatable. What I believe will make a change in dentistry—possibly due to the progress made in other areas—especially oncology—is that our patients will start to demand personalized medicine. I believe a new generation of students will be trained in a manner consistent with how modern healthcare should be; that is, personalized, predictive, preventive, and participatory.
As I see it, this approach offers another very exciting opportunity for both dentist and patient—the chance to prevent disasters. Among the worst experiences of clinicians is seeing patients who are very diligent about their oral hygiene regimen and regular in-office maintenance care, yet continue to deteriorate despite our best efforts. With early intervention in such patients, this progression can be averted, something that is very rewarding for the dentist, the staff, and, of course, the patient.
ID: How can we instill this Four Ps concept into everyday dental practice?
KK: This is a big tidal wave that will move across healthcare partly because the economics will demand it in medicine, but also because patients ultimately will demand it once they appreciate their personal stake in it. While dentists—like other healthcare providers—will be faced with the choice of either riding or resisting this wave, it is important to remember that dentists have long been leaders on the preventive side of healthcare. We have a historical partnership with our patients in preventing disease. The challenge of personalizing care will be in prediction, which is identifying people earlier. The focus should shift from the past history of disease destruction to measuring the markers that are more predictive of how the disease is likely to progress in the future, with and without treatment. That includes the risk factors that allow us to very nicely separate people into risk groups, given what we know today. Connected to this is the importance of communicating with the patient, something at which dentists are already adept. Once we identify an individual patient’s risk and are able to predict the path he/she is on, it is crucial that we make the patient aware of what we see. We need to discuss the implications in terms of our expectations and their expectations, clearly documenting that in our records, and making that information available to them.
ID: What do you consider a major “game changing” innovation on the horizon in dentistry?
KK: In addition to implants, which are here now and have completely changed how we think about cases and plan treatment, I see three very exciting developments, which might be more limited to periodontal disease and periodontal practice. This includes regenerative techniques, which connect to another wave occurring throughout medicine—the whole regeneration of organs and tissues. However, a “game changer” that has been around for several years that is likely to crystallize and have a dramatic impact in multiple ways is the periodontal–systemic disease connection. I think, first of all, it will pull us much closer to medicine, and in some situations, will even place some components of dentistry more under the medical umbrella in terms of education and reimbursement. It is also likely to rope dentistry into a different trend moving throughout medicine—that is, focusing on the biologic pathway rather than the specific tissue or the individual organ—so the different specialists can put aside their “orientations” and treat people who are susceptible to multiple diseases in different organs as a team, working together and managing that biologic pathway. These game changers are starting to move through dentistry and link up very tightly with major trends throughout healthcare, and I think there’s a very strong likelihood that, with good leadership in the profession, we will be able to take advantage of these game-changing breakthroughs.
ABOUT DR. KORNMAN
Kenneth S. Kornman, DDS, PhD, is the co-founder and chief scientific officer of Interleukin Genetics, the editor-in-chief of the Journal of Periodontology, and a lecturer at Harvard University School of Dental Medicine. He has been actively involved in research into genetic testing on common diseases of aging for more than 15 years. Dr. Kornman has published more than 125 papers in scientific journals, authored three textbooks, and is a co-inventor on more than 20 US patents. He was previously professor and chairman of the Department of Periodontics and professor of microbiology at the University of Texas Health Science Center at San Antonio.