October 2012, Volume 8, Issue 10
Published by AEGIS Communications
Dianne Rekow, DDS, PhD
The first American to lead a major dental school in Europe discusses practice-based research networks, the progress of technology, and why she considers her dual training in engineering and dentistry an advantage.
INSIDE DENTISTRY (ID): How and why did you move from the engineering sciences to the biological sciences, switching from engineering into dentistry?
DIANNE REKOW (DR): While working in engineering, I discovered dentistry’s extraordinary breadth of opportunities, ranging from the freedoms—and responsibilities—of private practice to the joys of discovery in intensely focused research. After 11 years in technical positions in industry, I returned to graduate school in engineering, simultaneously taking additional biology and chemistry courses with the hope of being accepted to dental school. Knowing of my dual interest, my advisor at the University of Minnesota, Arthur Erdman, PhD, was able to engage me in a joint project between the mechanical engineering and orthodontics departments at the University of Minnesota. Perhaps this was destiny, because it set me on a career path that could not have been more exciting. My dream became a reality, and I ended up weaving dentistry, orthodontics, and bioengineering into an amazing career.
Actually, the transition between these fields is not particularly radical. Much of engineering and dentistry is similar in many ways. Both require skilled problem solvers, depth in understanding materials and their performance characteristics, and creativity.
An engineering background has been enormously helpful in my career, partly because it created a background and language to understand and articulate potential opportunities in dentistry. Much of my work has been with interdisciplinary groups, where these skills have been enormously important. I strongly believe that multidisciplinary teams are becoming increasingly important and are essential in making paradigm shifts in our understanding. Having a background that crosses disciplines helps translate concepts between team members, moving us to common understanding faster, and in doing so, more can be acomplished and discovered.
ID: Having recently moved from your position as senior vice provost for engineering and technology at New York University, where you were also professor of orthodontics and of basic science and craniofacial biology at the College of Dentistry, to Dean of the Dental Institute at King’s College London, what do you consider the major differences between these educational models?
DR: What dentists know and what they are taught seem to be very similar, although there are, of course, many regional differences within the United States as well as between the United States and the United Kingdom.
At King’s—and throughout much of the United Kingdom and Europe—students earn their BDS degree in 5 years, beginning immediately after the equivalent of high school, so they are much younger when they begin their professional training and—except in rare circumstances—have not had the experiences of a first university degree and the associated inevitable maturation, life experiences, and depth of pre-dental educational background.
In the United Kingdom, as in the United States, clinical experiences are influenced by the patient populations seeking treatment. At King’s, a total of about 250,000 patient visits per year are distributed over four clinical settings, three of which are hospital settings. Two enable students to see ambulatory as well as hospitalized patients; there is also a team-based clinic that provides an experience similar to the four-handed dentistry training in the United States. Because of its scale, distributed delivery sites, and research interests in oral medicine and pathologies, King’s students see a vast array of patients, including those with relatively obscure pathologies.
With a BDS, graduates are qualified to practice, but if they wish to be registered with the National Health Service (NHS) and be able to treat NHS patients, they must have an additional year of training under the direction of one of a deaneries outside of the university system.
Graduate specialty training programs seem to be very similar in the two countries, except for their duration. At most UK universities, the PhD is expected to be competed in 3 to 4 years, in contrast to the usual 7-year programs in the United States.
Another startling difference is the matter of tuition, which, until this year, was not charged at most UK universities. Although that has changed, students will not need to pay out of pocket; the tuition will be structured as a loan to be repaid after the student begins working. Such loans are not available to students seeking additional degrees, who must pay required tuition at the beginning of each year of training.
Major differences exist between the US and UK systems in terms of those engaged in setting educational standards, directions, registration, and funding. In the United Kingdom, the General Dental Council (GDC), the Royal Societies, the NHS, and the Deaneries all interact with the University in various ways. Government agencies set limits on the number of undergraduate students that can be accepted, which determines the government-provided funding levels shared between the University and the Foundation Trust hospitals. The complication of understanding the roles of each of these is one of my more interesting challenges, and a full description of how they interact would surely exceed the limits of space available here.
ID: Having been involved in early CAD/CAM designs, what were its challenges? Seeing where CAD/CAM is today, could you have envisioned that 20 years ago?
DR: The most significant challenge we faced was that our imagination exceeded the technology. Our goal was to create a CAD/CAM system capable of fully automating creation of posterior, full-coverage molar crowns with quality equal to a cast crown. We made this choice because it represented the most challenging demands; posterior crowns have the most geometriccomplexity and are in the most difficult sites for acquiring data.
One of our major limitations was the computational power in the late 1970s and early 1980s, which prevented us from realizing a fully automated system. It is satisfying to see the strides made by so many companies now producing systems. It is also frustrating to remember how many potential investors told us CAD/CAM systems were unnecessary and would never be viable in the marketplace. Many of the systems now available have realized our performance goals, meeting the objectives we had in design specifications articulated over 20 years ago. So, while it is satisfying to see that our vision was possible, it is disappointing that development on our envisioned system halted and that it is not among those now commercially available.
Today’s CAD/CAM systems predominately use a subtractive production approach, but evolving and maturing technologies are exploring an additive approach whereby materials are placed or cured only in the areas required for a restoration to be created. One particularly exciting aspect of some of the additive approaches is that combinations of materials can be used in different ratios in different locations. The practical implications of this for a crown are that it could be created with a high-strength core material that could change to an esthetic surface smoothly and continuously, without requiring the usual well-defined core-veneer interface. This change could dramatically improve the damage tolerance of all-ceramic crowns. It could also improve esthetics, because different shades of esthetic materials could be deposited in specific areas of a restoration, more nearly mimicking natural tooth shading.
CAD/CAM technologies have already opened possibilities for new materials not previously practical for restorations. Most notable to date is the emergence of zirconia-based restorations. Synergy between CAD/CAM technology and material science will likely be more and more exciting as both fields continue to mature.
ID: What was the basis for NYU Dental School’s receiving a $2 million grant from the Department of Homeland Security (DHS), and what does it mean for dental education?
DR: Our DHS-sponsored activities have had an important influence on education, both at NYU and in other areas of the United States. We had two different but complementary funded grants.
In the first grant, our objective was to investigate and evaluate how to appropriately involve dentists in first-response activities as part of an overall DHS-led system, not acting on their own. A number of new policies have been put in place in some jurisdictions that now engage dentists more fully in emergency response.
In the second, we were able to model implications and outcomes of various responses. One outgrowth of our effort was—on two occasions—the involvement of several dental, medical, and nursing students and faculty in a 1-week training program with the Army at Fort Sam Houston in San Antonio. This was an amazing eye-opener, giving us lecture-based information about an array of potential threats and appropriate responses as well as field experience of selected situations, including operations of field triage and treatment—all in 100° heat.
David Glotzer, DDS, and Walter Poster, DDS, PhD, both at NYU, have incorporated much of what we learned into the dental curriculum. In the first year, students learn the basics—what to do in a fire drill, how to evacuate a building, etc. In the second year, when students normally learn about pathogens and viruses, they also now learn about pathogens that could be bioterrorist agents. In the third year, they start learning to recognize the clinical manifestations of such biological agents. However, what I particularly like is that in the fourth year, there is a component in the practice management course where each student writes a preparedness plan for his or her own practice. Their plans are geared toward the environment in the area where they expect to practice.
ID: From your leadership positions in both the International Association of Dental Research (IADR) and the American Association of Dental Research (AADR), how would you describe the state of dental research today? What three items would you include on a simple straightforward priority list for the focus of dental research?
DR: Craniofacial-related research is very strong, but I think it’s often underappreciated by our colleagues outside dentistry. While remarkable things are being investigated and reported, I am concerned that the research prowess of the dental faculty and the impact of the research are not always as well respected as they should be. I hope that as we learn more about the connection between oral health and systemic health that there will be an improvement in the dialogue and respect between professional communities.
Funding for research is always critically important. The success of new faculty is heavily influenced by their ability to secure federal research funding. Limited and/or falling funding levels force many to leave academia, which is particularly troubling as we simultaneously wrestle with trying to increase the number of people interested in pursuing academic careers needed to secure a vibrant future for the profession and dental education.
As for my dental research priority list, it would include: 1.) gaining a better understanding of the interface between the biology and materials—both biologic and non-biologic—that we use to manipulate and restore function; 2.) higher-resolution imaging and non-ionizing radiation to track the evolution of pathologies and restoration of health; and 3.) stronger collaboration across disciplines to exploit knowledge and technology for greater understanding of physiologic functions at all length scales from cellular to dental–systemic interactions.
ID: How can members of the dental profession at large play a greater role in setting the directions for research?
DR: One important way individual practicing dentists can be involved in driving research is to be involved with one of the practice-based research networks. In the United States, these networks have largely been funded by NIDCR, but similar activities have been in place for some time in other countries, including England and Scotland. Through the networks, clinicians help define the questions being addressed about the procedures they already perform. Then the outcomes of the procedures and/or patient’s perceptions of the outcomes are analyzed and reported. Practitioners, in large measure, continue to do what they’ve been doing while gathering information about procedures they and others in the network perform. The results of the studies are shared with the network and other clinicians, permitting them to evaluate the efficacy of procedures and materials across practices, as well as analyzing the implications of the study on how they choose to practice. This enables practitioners to have access to quality information much faster than would be possible in an academic environment.
The networks also enable clinicians to evaluate the evidence base of dentistry. The findings from the studies often identify gaps in our knowledge. Importantly, the networks provide an intelligent platform from which to make decisions about future materials, procedures, techniques, and new research priorities.
ID: What do you think may be the next big breakthrough technology for oral health and the delivery of dental care?
DR: While there are many exciting developments now and on the horizon, I believe salivary diagnostics will be important for future, and that we’ll gain a better understanding of the disease process. To be able to understand thecomplexities of the body from saliva is quite remarkable. With future breakthroughs, we can envision new ways of diagnosis and measuring restoration of health in fully developed counties as well as across geographies that have historically lacked sufficient infrastructure for blood and urine tests.
In tissue engineering, highly effective scaffolds are an important step in delivering the proper initial support to create the appropriate tissue combinations to restore natural tissues that can then resorb with no negative side effects. A remarkable a complishment would be to create a complete tooth with all of its layers, its functionality, in the right place, and with the proper anatomy.
It is also important to find new ways of improving the probability that a tooth be able to last in neglected environment, without the necessity for the self-care, as well as more effective ways to engage people in delivering the currently needed self-care. We must also continue to address healthcare delivery challenges posed by lack-of-access issues but also those of access of care, motivating those who already have access to use the oral healthcare services available to them.
ID: Looking toward the future, what would be a disruptive technology that would severely impact dental practice as we know it today? What technology used today will likely be something of the past?
DR: An intelligent coating of some sort—eg, something that turned purple if your blood sugar level went too high—would be hugely disruptive and very positive. This may already be in the realm of possibility if we engaged multidisciplinary teams to explore the question.
As for technologies that could get phased out, my hope is that we can find effective alternatives to ionizing radiation. Also, it would also be hugely impactful if we could find ways to preserve natural oral tissues, so restoration becomes a thing of the past.
About Dr. REKOW
Dianne Rekow, DDS, PHD, is currently Dean of the Dental Institute at King’s College London. At New York University (NYU), immediately before joining King’s, she served in various roles including as senior vice provost of engineering and technology and provost of Polytechnic Institute of NYU, chair of the Department of Basic Science, professor of Orthodontics, and was the principal investigator on an NIDCR-funded grant to explore damage initiation and propagation in layered ceramic materials. Before joining NYU in 2002, she served in various academic positions at the University of Medicine and Dentistry of New Jersey, the University of Maryland at Baltimore, and the University of Minnesota.
Dr. Rekow is past president of both the International and American Associations for Dental Research and is an internationally known authority on the performance of ceramic materials in esthetic and restorative dentistry. In addition to her dental degree, Dr. Rekow holds Bachelor’s degrees in physics/mathematics and mechanical engineering, a Master’s degree in mechanical engineering, an MBA, a specialty certificate in orthodontics, and a PhD in biomedical engineering.