Dentistry: The Future
The adoption of new technologies in dentistry
This article examines some of the future developments in dentistry as predicted in the American Dental Association's Future of Dentistry report and some of my personal predictions.
Developments and innovations in other fields such as materials and computer science invariably feed into dentistry affecting the techniques and materials used. However, compared to other fields such as electronics, aeronautics and medicine, dentistry is regarded by many as being slow to embrace new technologies.
One example of this was the adoption of x-rays into dental practice. Discovered in 1895 by Wilhem Roentgen the technology was included for diagnosis of disease and fractures by physicians fairly rapidly. However, it wasn't until 1918 that teaching about x-rays was included in the dental school curriculum and the early 1930s that x-ray machines were commonly found in dental practices.
A more recent example might be dental implants which are just starting to be offered fairly widely some 40 years after their introduction.
To be embraced into general dental practice any new technology needs to prove that it is at least as good and reliable as the current method(s), and it must offer time or cost savings or some other advantage(s).
The introduction of both implants and x-rays into general dental practice conform to the recognised pattern of the adoption of disruptive technologies (see below). First, a small group of adventurous or foolhardy souls try out or develop new techniques or materials. This group is followed by a larger group of early adopters who wait to see initial results before trying the water. Then the majority gradually follow over a period of time and pulling up the rear are the stragglers who are the last to adopt any new techniques preferring the safety of what they know. This whole process of uptake from the innovators to the laggards is said to take no less than 30 years.
And there are several reasons for this.
As a dentist in general practice you don’t want to be one of the first to adopt a technology or procedure that is later found to be faulty. This can prove very expensive, can damage your reputation, lose you patients and may ultimately see you locked in litigation. On the other hand, market pressures dictate that you will lose custom if you are not offering various technologies when other dentists are.
Another factor affecting uptake is the speed with which insurance companies and the National Health Service in the UK will agree to remunerate for new techniques and materials and this can significantly delay the introduction of disruptive technologies into dental practice.
The adoption curve
Diagnostic digital radiography and tomography in dentistry
Digital radiography uses one-tenth of the dose of radiation of traditional radiography. It also enables a digitised comparison with previous x-rays so that areas of bone loss or growth and tooth mineralisation or demineralisation can be closely monitored. Digital x-rays also offer other advantages in that they are immediately available and can be stored, organised and retrieved readily. They can also be digitally manipulated to increase contrast and so forth to highlight problem areas. They also do not require chemicals for development and are not subject to the problems inherent in ensuring concentration and freshness of developing solutions and human error problems whilst developing traditional x-rays.
Cone beam computed tomography (CT) enables dentists to get the same sort of information as they would from a CAT scan in house and at a fraction of the cost and radiation. This is particularly useful when placing implants to assess bone quality and quantity, for extraction of wisdom tooth extraction and in relation to endodontics. I wonder if it may also lead to the widespread detection and acceptance of the existence of jaw cavitations when the bones are visualised in 3D?
Optical coherence tomography (OCT) uses the differential optical scattering properties of near-infrared light by biological tissue to produce high resolution 3D images.
Future developments in relation to the above imaging systems will probably see software that can propose implant positioning, and provide automatic alerts in relation to potential pathologies and asymmetries.
Soft and hard tissue lasers in dentistry
Diode lasers are currently being used by some dentists primarily for soft tissue management during surgery and offer several advantages over the use of electrocautery which is problematic when used around metals. In addition to its use on soft tissues, lasers can also be used to selectively remove decay and also to treat the cavity thus preventing a recurrence of decay around the restoration.
Specific pulsed laser irradiation has been shown to alter the surface of the tooth enamel making it highly resistant to acid dissolution. At present this is only in the research phase of development, but the hope is that the pits and fissures of the teeth which are most vulnerable to decay may be able to be treated prophylactically in this way in the relatively near future.
The prevention and reversal of dental disease
Since the widespread acceptance of Pasteur's germ theory and the discovery of the bacterial nature of both tooth decay and gum disease, dentistry has been firmly rooted in an era dominated by the study of the causative microbes. This approach has given rise to efforts (so far unsuccessful) to produce vaccines against caries and periodontal disease.
With the discovery of the structure of DNA in 1953 and the completion of The Genome Project in 2001 attention has now turned to the genetic basis of disease. Many of the technologies in development are now focussing on issues relating to the human and microbial genome.
This includes computerised in-house analysis of samples of saliva, plaque and blood using genetic tests and biologic assays combined with software which analyses familial dental and medical histories to assess an individual's risk for tooth decay or gum disease. Ultimately this data might be used as a basis for determining dental insurance premiums - for good or ill.
The concern is that gemonic technologies will be developed because we are capable of doing so rather than because they work. When electricity was first discovered there followed an era when it was applied enthusiastically to all disease and as we now know with few exceptions did not prove effective.
Other techniques using antibodies to tag the bacteria associated with tooth decay which can then be detected using fluorescence and measured photometrically have also been developed. This technology would enable rapid, chairside assessment of the current risk posed to the teeth by the oral flora.
Antimicrobial gels and other products for placement in periodontal pockets by the dentist or hygienist may be used perhaps in combination with systemic antibiotics targeting the microorganisms involved in aggressive periodontal disease, or for medically compromised patients. The development of other pharmaceutical drugs for the management of periodontal diseases could also alter treatments that have traditionally relied on surgery, mechanical therapy and plaque control.
Ozone is also currently in use by some dentists and has been shown to destroy 99% of the microorganisms found in root decay and to promote remineralisation of the tooth. It can also be used on decay in the pits and fissures of the teeth and especially in the deciduous teeth of children and has applications in an estimated half of all cavities. By avoiding the necessity of cutting the tooth initially many of the sequelae ie: re-restoration, devitalisation, root fillings and crowns are avoided.
Then there are the products being developed for home use to prevent, arrest or reverse dental disease including various chemotherapeutic agents in toothpastes, mouth rinses, oral irrigation and sonic devices and possibly the use of ozone and/or specific lights.
Computing and digital technology in dentistry
Computer aided design and manufacturing of restorations (CAD/CAM) has been adopted by some dental practices but still remains prohibitively expensive for the majority of practitioners. This piece of kit can be used chairside to scan preparations and machine restorations or digital image/impressions can be transmitted directly to a laboratory for manufacture of the restoration(s) off-site. With chairside fabrication, restorations can be completed in a single visit saving time and the necessity of making and wearing provisional restorations. The time saved may help to keep the total cost to the patient down.
Other uses of CAD/CAM technology include manufacturing surgical templates for implant placement and orthodontic systems such as Invisalign® which uses a series of transparent machined removable braces to effect orthodontic tooth movement.
Additional applications of computer technology include better diagnosis of decay and tooth vitality, shade matching, and analysis of occlusion, temperomandibular joint (TMJ) and neuromuscular problems. Technologies using ultra-sound and/or electrical impedance to detect tooth decay are also in development.
Many dental practices already use computerised systems for their practice management, practice and patient record keeping, photography and patient education. And further integration of voice activation, 3D, touch screen, real time visualisation, magnification and wireless technologies can be anticipated along with miniaturisation of equipment.
Both dental training and the practice of dentistry may look radically different in 15-20 years with off-site consultations and education over the web. The growth of the internet also means that manufacturers and laboratories around the globe can deal with dentists directly. And the web also enables the rapid dissemination of information amongst the global dental community with online journals enabling faster publication, dental forums, webinars, teleconferencing and real-time language translation.
The new frontier in restorative dental materials
Dentistry from its inception up until now has been in an era of xenodontics. That is that it has relied upon materials foreign to the body such as metals, plastics, glasses and ceramics to restore diseased dental tissue. And developments of the current materials available will continue to be made with increasing use of non-metallic zirconia crowns and dental implants and castable fluorapatite glass-ceramic materials. Improvements in the composite materials used to restore posterior teeth are in the pipeline and in particular interpenetrating-phase composites which are based on infiltration of a porous, three-dimensional ceramic skeleton with resin.
For those that aren't a fan of the high whine of the dental drill, they are likely to become powered by electricity rather than high pressure air and high-pressure silicates are also already in use to 'sand blast' away diseased tooth and roughen surfaces.
Another promising technology currently in development involves three-dimensional printing using powder/binder combinations followed by sintering to form solid objects from ceramics or alloys. This also allows for a gradation in the materials based upon their different physical and aesthetic properties.
Research is also currently being conducted into 'actively smart materials' that is, restorative materials that incorporate therapeutic agents that are released over time or when disease is active. Such materials may be able to stimulate the growth of new or secondary dentine in decayed teeth.
However, the main area of advance will undoubtedly come from the field of biodontics which is the development of biologically based materials of cellular origin for restoration and regeneration of diseased tooth and supporting structures.
At present bone regrowth around teeth and dental implants is achieved using combinations of either human freeze dried bone, or materials derived from sea coral often combined with the use of resorbable or non-resorbable semi-permeable membranes which can be either synthetic or of animal origin in a process known as guided tissue regeneration (GTR).
Various scaffold materials are currently being engineered which may carry cells, growth factors and molecular species designed to direct and enhance bony repair. And enamel matrix proteins are being developed which promote regeneration of tooth enamel.
Synthetic saliva products for the elderly and those who suffer from dry mouth may be developed. And genetically engineered antibodies are currently under development as a tool for inhibiting colonisation of the teeth by specific cariogenic bacteria.
The understanding that every tooth has a life cycle and that the more tooth substance that is removed the more you accelerate the process and the hasten the ultimate loss of the tooth will hopefully become commonplace. This approach incorporates adhesive and minimally invasive dentistry which seeks to conserve as much tooth as possible at each stage.
Back to the future: The recognition of the oral-systemic disease connection
Our understanding of the connection between systemic disease and the status of the mouth will hopefully grow. And this is no new frontier as Willoughby Miller set out the issue in some detail in a paper in 1891. He suggested that oral microbes and the toxins they produce can travel in the blood stream and along tissue planes to produce a variety of diseases distant to the source. He cited examples including brain abscesses, pulmonary diseases and gastric problems, as well as a number of systemic infectious diseases. The British physician, Sir William Hunter then took up the cause.
"In my experience septic infection is without exception the most prevalent infection operating in medicine, and a most important and prevalent cause and complication of many medical disease. Its ill-effects are widespread and extend to all systems of the body. The relation between these effects and the sepsis that causes them is constantly overlooked, because the existence of the sepsis itself is often overlooked. For the chief seat of that sepsis is the mouth. Gold caps and .. gold bridges, built in, on and around diseased teeth, form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine or surgery."
Sir William Hunter, as reported in the Lancet 1910
Others followed in their wake but the concept of an oral focus of infection was largely abandoned in the 1930s only to be resurrected in the last couple of decades as the evidence has become incontrovertible. The microbes themselves can either be aspirated (causing pneumonia) or the microbes and/or their toxins can enter the circulation and travel to any tissues.
The association between periodontal disease and a number of systemic conditions including coronary heart disease, stroke, adverse pregnancy outcomes, diabetes and bacterial pneumonia has now been established and in 2001 the US surgeon general’s report highlighted this issue.
It is really crazy that you should even need to point out that oral infections might affect systemic health, but thinking has become so fragmented that many would argue the point vociferously. The fact is that the mouth is an integral part of the body which works as a cohesive whole and any and all diseases and interventions affect the whole organism. Dentists are uniquely placed to both help and hinder the general health of the patient since up to 90% of disease is said to have an orientation in the mouth. Hopefully they will come to understand their role in both healing and the creation of chronic illness.
The poor relation: Nutrition
So germ theory led us to believe that we were under attack from hostile microbes and genomics which has currently replaced it leads us into thinking that we are inherently faulty and in need of correction.
Both are wrong thinking.
Our bodies are perfect.
It is the way we are living and particularly eating that is at fault and no fancy technology is addressing that because no fancy technology is required and there is no money to be made from it.
Many decades ago the US dentist Dr Melvin Page DDS was making remarkable use of a series of simple measurements and blood tests to not only arrest and reverse dental disease, but as a corollary to reverse systemic disease too. He did this by having patients eat simple fresh, unrefined foods and by supplementing vitamins and minerals and tiny amounts of endocrine extracts.
The work of Dr Weston Price (see the book review of Nutrition and Physical Degeneration) and the fossil record also tell us that while there will always be a need for cosmetic dentistry the dental ills that dog us are largely of our own making and have to do with the industrialisation of food production. Which means that you have it within your own power to choose differently for your self and your children right now. However, I hope that some meaningful instruction in nutrition possibly allied with analysis of an individual's blood chemistries comes to be offered as a matter of course by the dental profession.
The fact is some technologies aside, the new era of dentistry is already here being practised by a small group of biological and holistic dentists who are often hounded and pilloried. They focus on the use of materials biocompatible to the particular individual, nutritional support for maintaining oral health, the effect of focal oral infections from root canalled teeth and extraction sites, energy disturbances and the structural effects of treatment upon the whole body.
I also hope that there is wide acceptance of the energy system of the body as being revealed in recent thermal images (see Infrared Imaging Reveals Meridians and Acupuncture Meridians Revealed by Thermal Imaging) and the effects of dental procedures upon the meridians.
Finally, inclusion of the equipment currently being used by some natural practitioners into dental practice such as thermography, biomeridian testing, and polycontrast interference photography really would be exciting and mark a paradigm change.
“First they ignore you, then they laugh at you, then they fight you, then you win.”