Special Series: The New Frontier

By 2010, the bioscience discoveries of the preceding 50 years had emerged from research laboratories to become the next generation of diagnostic and therapeutic products. Some of these innovations have included the discovery of DNA as the genetic material; the double helical structure of the DNA molecule; the sequence of the human genome; the potential of stem cells for tissue regeneration; the use of bioscaffolds for regeneration of destroyed dental tissues; progress in the development of vaccines for caries and periodontal disease; and the use of biomarkers in saliva for diagnoses of diseases, including cancer. All promised a revolution in the health sciences, including dentistry. Based on these advancements, many in the dental profession realized that the two scientific principles guiding 20^th century dental practice—namely, dental diseases (caries and periodontitis) were caused by microbes and tissues (enamel and dentin) could not regenerate—had to be reformulated. An alternative theory of diseases that included genetics and epigenetics of dental structures, involved teeth and bone, emerged after a reconciliation of the new and traditional views.

However, in contrast to 1910 when new theories and technology were embraced by the profession, dentists in 2010 have not been as welcoming to alternative theories or the bioscience-based technology. The differences are striking and suggest alternative forces are affecting dentists’ attitudes.

The signing of the Vietnam peace treaty in Paris in 1973 ushered in unprecedented peace and prosperity in the US. A sense of trust prevailed as many were living the American Dream and the stock market continued its almost meteoric rise. But neither the calm nor the optimism were to last.

On September 11, 2001, extremists hijacked four commercial jets, crashing one into the Pentagon, two into the World Trade Center, and another in a Pennsylvania cornfield. In response, the US attacked Afghanistan. This was followed by the war in Iraq.

While we were embroiled in external conflict, the presidential election of 2000 raised questions about our internal political system. The financial horizon began to darken, and by the end of 2008 the country’s economic prosperity had ended. For many, the recession of 2008 was reminiscent of the Depression because of the record-high unemployment and the wealth of ordinary Americans dissipating. The collapse of the American banking system was the event of the decade. Americans expressed their frustration in the voting booth and changed the political parties in the White House.

The cumulative effects of 2000 to 2010 may have rippled into dentistry. Scientific and technologic advances were accepted rapidly into dental practice in the year 1900 but not in 2000. Scientists and engineers, a group that Americans considered truthful and trustworthy, became embroiled in controversy and fought among themselves about energy and the environment, global warming and climate change, polluted drinking water, the plastic used in infant bottles, and the oil spill off the coast of Louisiana.

In 1900, scientists and engineers promised and delivered improvements in communication, transportation, and health. However, by 2000, the population had begun to question the positive value of scientific achievements. This distrust may have been responsible for many dentists not adopting the bioscience technologies emerging from the discovery pipeline. Some dentists would think twice about moving from the diagnostic and therapeutic procedures in use for decades to those that were based on theory and might produce unintended consequences. Perhaps patients might have expressed unease with the appearance of new equipment and procedures in the dental office.

In 1900, the situation was very different. The pain associated with the repair of decayed teeth and the poor replacements available for extracted teeth made the patient eager to embrace any improvements. However, the dental patient of 2000 was quite different, desiring a beautiful, white movie-star smile. The dental profession could deliver this painlessly. Why change by introducing bioscience technology that could tell the patient that he or she had cancer, for example?

While many patients received better smiles, many others had poor or no access to dental care. This problem was documented in 2000 when the US Surgeon General issued the first-ever report on oral health in America, calling attention to a significant number of people without access.

The report mobilized advocates, who wanted changes in the healthcare system. One of their first goals was to increase the number of providers. In 2000, the US had an estimated 160,000 dentists, serving more than 300 million Americans. Heeding this call, the profession opened several dental schools. The number of graduates increased from approximately 4300 in 2000 to an estimated 5000 in 2009. To raise the quantity of providers, activists turned to an experiment begun in Alaska: the accreditation of dental therapists. The Minnesota legislature created a licensure program for such professionals to perform cavity preparation, restoration of primary and permanent teeth, pulpotomies, and extractions of primary teeth. This legislation, together with changes such as enhanced duties for hygienists and dental assistants, suggest the “manpower” may now be sufficient to provide for the needs of our population.

Given the demand for access to dental care, the decade from 2010 to 2020 is likely to involve a change in the cottage industry model for the delivery of dental services. States used to mandate that only dentists could own dental offices, which effectively limited the number of access points. While owners could hire other dentists, they could not use dental therapists to increase the access points. Some states have enacted legislation that enabled hygienists to open “independent” practices. However, this change has done little to help. In early 2000, the 1980 chain-store dentistry idea was revived. As a result, many states changed their laws and removed the requirement that a dental degree was needed to own a dental office. Since then, companies have opened dental offices, providing additional access points for dental care.

The acceptance of scientific advances and innovative equipment is more a function of political change and social attitudes of dentists and patients than the validity of science or the success of the technology. In the next few decades, dentists and patients will overcome their fears and the profession will enter its next frontier—bioscience. The timing of when this bioscience is accepted into the dental office and the curricula depends not only on the value placed on the science and technology for patient care but also the attitudes of dentists and patients toward science in general. When these groups believe bioscience technology will add to quality of life, these changes will be embraced. Some dentists have already crossed into the new frontier: they are Biodontists, who use cellular materials to replace, restore, and repair lost and missing teeth and tooth structure. In the future, most dentists will be Biodontists.

Edward F. Rossomando, DDS, PhD, MS
Professor
University of Connecticut School of Dental Medicine
Farmington, Connecticut

Director
Center for Research and Education in Technology Evaluation
Farmington, Connecticut