The Legacy of Dental Research

SIDEBAR 1

Perspectives on How & Why Dental Research Has Changed Dental Practice
On a day-to-day basis—whether at work or during our leisure time—we enjoy and take for granted so many of the technological applications that resulted from scientific research. Science and technology make a difference in everyone’s life every day, and dentistry is no exception.

To feel the impact that science and technology have made on what we do and how we think, as well as how we’re already—maybe even subconsciously—changing the way we do things now, it’s worth taking a look at the way things were in years gone by. Doing so provides cascading “Gee,” “Hmm,” “Why didn’t they think of that sooner?” and “Yes, I see how that made sense” reflections. It also drives home the realization that evolution within the dental profession is ongoing and continuous. The greatest and most thorough knowledge and understanding within dentistry is yet to come.

“The legacy of dental research is that it reviews the past, modifies the present, and creates the future,” explains Tony Volpe, DDS, MS, the vice president of clinical dental research and scientific affairs for Colgate-Palmolive Company and a clinical professor of periodontics at the University of Medicine and Dentistry of New Jersey Dental School. “Research is the cornerstone of progress not only for the practice of dentistry, but also pretty much all endeavors in life.”

RETENTION, PREVENTION, AND PATH OF LEAST INVASION

Once upon a time, when someone had cavities or otherwise diseased and decaying teeth, they were extracted—no questions asked. After all, centuries ago teeth with cavities were akin to limbs with gangrene. They had to be amputated, explains Tony Winston, a research fellow from Church & Dwight.

Then, in the 1800s, the idea of removing only the diseased portion of the tooth and filling it in was developed. The original material was lead, which soon gave way to mercury amalgam, Winston notes. Since then, the resilient amalgam material has been the mainstay of surgical dental treatments.

“Amalgam really was an amazing breakthrough,” Winston says. “In the future, emerging materials and techniques will allow you to detect early signs of a carious lesion in a tooth and then, instead of actually drilling and filling—which is damaging to the tooth—use therapeutic medications to reverse the disease and stop it.”

With fluoridated water and fluoride toothpastes in the 1950s and 1960s, the era of preventive dentistry began, leading subsequently to topical fluoride solutions, gels, and varnishes. The focus on the prevention of dental disease—not just the treatment of it—also led to increased interest in oral health education in hopes that preventive measures would have a positive impact on children’s oral health.

“This is very significant,” Volpe says. “Prevention wasn’t something that was done before, but then it became important to the profession.”

It became important to the public, also. The introduction and later widespread use of toothpastes containing fluoride demonstrated that teeth could be retained caries-free for years.

But that wasn’t always the case. Looking back to the 1950s and 1960s, by the time a patient reached the age of 75 or so, they’d had teeth extracted and dentures fitted, Volpe notes. Also, full-mouth fixed prosthetics were once acceptable. But, such restorative treatments were shown to produce less than ideal occlusion, as well as result in difficulties in trying to repair or modify these appliances, Volpe explains. As a result, things changed.

Research also contributed to changes in the manner in which periodontal therapies are performed. Until recently, there were basically two modalities to treating periodontal disease, Winston explains. One was root planing and scaling, which, if performed correctly, would require several hours spanning several office visits, with the clinician working quadrant by quadrant. The other was gum flap surgery, an invasive procedure that, very often, didn’t stop the progression of the disease, he says.

But when research demonstrated that periodontal disease progresses in certain patterns—not necessarily affecting all teeth or all tissues around teeth—the need for total mouth periodontal surgery was eliminated, Volpe notes.

“Now we selectively deal with periodontal surgery and selectively administer subgingival therapeutic agents,” Volpe says.

SPECIALIZATION

With increased and specialized knowledge came dental specialties—periodontics, endodontics, orthodontics, and the like. Volpe notes that these disciplines came into full maturity within the last 30 or 40 years, and their significance in the profession is more widely recognized.

“Individual dentists were doing the best they could, and sometimes referring patients out for more work, but it wasn’t in the organized structure that it is today,” he says. “When specialties became really entrenched, there became educational programs accredited for them, and they have become tremendously important to dentistry.”

INFECTION CONTROL

With the understanding of bacteria came an understanding of infectious diseases. As a greater understanding of that area was researched and developed, so too was the need for infection control. And necessity, as they say, is the mother of invention.

“If you went to a dentist 30 or 40 years ago, there were no face masks, no gloves, really no central sterilization mechanism, and no disposable instruments,” Volpe recalls from his more than 45 years in dentistry. “Today, we have protection for ourselves as well as the patient. All of this has made a dramatic and significant impact on the way dentistry is practiced today.”

EFFICIENCY

With the introduction of the high-speed handpiece in the 1960s, dentistry was relieved of the pulley system with a push down pedal.

“This was laborious, it was time-consuming and inaccurate, and it wasn’t a pleasant experience for the patient,” Volpe remembers. “When the high-speed handpiece came, it changed all of that. All of a sudden, we were able to create restorations faster, better, and with less discomfort to the patient.”

For this reason, he considers this innovation among dentistry’s absolutely significant breakthroughs. Lawrence Tabak, director of the National Institute of Dental and Craniofacial Research, also points to innovations that have affected patient comfort as important to the profession.

“Before the advent of local anesthesia, as well as before the high-speed handpiece, many folks tell horror stories of how dentistry once was,” Tabak says. “Modern dentistry is relatively painless, and I think most patients now appreciate that.”

But under the category of efficiency came other more recent, high-tech advancements, such as digital radiography, voice-activated recordings and computerization of information, and modern implantology. According to Volpe, all of these have dramatically changed the way dentistry is practiced in the modern era.

ESTHETIC DENTISTRY

The introduction and advent of new dental materials have changed dental practice, Volpe says. Composites that can be used for fillings instead of amalgams, as well as new porcelains for fixed prosthetics, have helped usher in the age of esthetics.

“All of these materials are very esthetic in contrast to the gold and amalgam fillings we used to use,” Volpe observes. “They were fine restorative materials, but they weren’t very esthetic materials.”

But, looking ahead, Volpe predicts that the research taking place today may result in recommendations for how to handle esthetic restorative procedures—including implants—in the future. Current research will help modify the revolutions taking place in esthetics and implants, he says, just as it helped modify the materials and techniques of the past.

“I think research will show us that we have to be more prudent about what we do to teeth to achieve the esthetic effect—whether we etch them, bond to them, or whiten them—because it isn’t always reversible,” Volpe says. “With implantology, it will show that we have to consider the periodontal aspects and the impact on bone and other superstructures, and it will help us understand the condition called peri-implantitis.”

ORAL/SYSTEMIC HEALTH AWARENESS

As research amassed to gain an understanding of periodontal disease and the bacteria that cause it, the increasing knowledge base was a foundation for connecting oral health to overall health. Simultaneously, there have been great leaps forward in the use of antimicrobial and antibiotic treatments to ensure periodontal health, Winston says.

“Attention is being paid to the connection between oral disease and systemic health,” Volpe points out. “In other words, the mouth could be a source of infection for the rest of the body; it could be linked to a certain extent to diabetes or other things of this nature, for example. The fact that people are talking about this link is changing the dynamics of dental practice.”

SIDEBAR 2

From Questions to Answers and then to Application, It Takes a Lot to Make Research Real

What makes today’s groundbreaking research possible is a product of perception and position within the dental profession at large, if not the research community itself. Some of the best ideas for what to study and what research to conduct come at the interface between different ways of thinking, believes Harold Slavkin, DDS, dean of the University of Southern California School of Dentistry. And people, first and foremost, are at the heart of those interfaces.

“From the synthesis of ideas from chemists, biologists, dentists, and others, a new idea is born and a new way of thinking is developed,” he explains. “The most impressive breakthroughs in any areas of humanity come at the interface between different ways of thinking.”

The Power of People

According to Slavkin, to make meaningful dental research possible, there must first be a perceived value. “Among all of us who are in the dental profession, there needs to be a personal and professional value of science and technology,” Slavkin says. “If we do not value and utilize innovations, discoveries, best practices, and evidence-based patient care, our future will not look very good.”

Perceived value of science and technology can then translate to support for research endeavors through local universities, organized dentistry, and dental manufacturers, as well as funding by the federal government.

Secondly, there must be advocacy for improvement throughout the profession. When members of the profession are only interested in the status quo, there is no need for research, Slavkin says. “In fields where people become complacent, research dries up, so advocacy for improvement must be a prerequisite for dental research,” he explains.

Third, an emphasis must be placed on the cost-benefit relationship of the research to dental practice and/or patient health. In some circles, this emphasis is realized through translational research, that which can show a direct link between what is being studied and how it will be applied in day-to-day practice.

Finally, positive attitudes and appreciation for research must be fostered in dental school education programs so that faculty, staff, and students can become engaged in the process, Slavkin says. This point in particular lends itself to the number one criteria for enabling dental research on Christopher Fox’s list: people.

“You need a pipeline of researchers,” says Fox, DMD, DMSc, executive director of the International and American Associations for Dental Research (IADR/ AADR). “That means encouraging students to pursue academic and dental research careers.”

Dominick DePaola, DDS, PhD, president and chief executive officer of The Forsyth Institute, agrees. In his opinion, it is critical to begin engaging students in research early on, while making it clear when they graduate that they shouldn’t leave research behind. Rather, graduating dental students should carry with them their ability to be critical thinkers capable of evaluating the literature and new technologies and making informed decisions about what might be in the best interests of patients and their practices alike, he suggests.

Facilities & Funding

Fox also indicates that there needs to be an infrastructure in which to conduct the research—laboratories, facilities, buildings, equipment, etc. Where the research is conducted could range anywhere from biomedical institutions to dental schools, and from health science centers across the nation to private practices, notes DePaola.

“The kind of institution that you work in will determine how research ideas are nurtured and ultimately cultivated,” DePaola says.

And every research institution—and initiative—requires funding.

“We are never going to have as much funding as we have research questions,” Fox observes. “So the research questions must be prioritized.”

“The development of any idea into a really serious research enterprise requires significant funding, and the funding has to come from a variety of sources,” DePaola stresses. “These include the NSF, NIH, and NIDCR, but certainly they’re not the only sources. The dental industry has been a big source of funds, as well as philanthropy, other non-dental corporations, and Big Pharma.”

Fox encourages dentists to stay abreast of what is taking place in the dental research community and support research funding by being involved in the political process. The latter, he says, requires a conscious effort to ensure that their Congressional representation really knows about the importance of dental research.

“If I were to add up the amount of money that the American people have given to the NIDCR since 1948, it is much less than a billion dollars,” explains Slavkin. “On the other hand, when I look at the benefits of the research—the health and quality of life that have resulted directly from that institute—there is a national savings of $4 billion per year.”

Compared to the $2 trillion dollars that Americans spend on health care, the investment made into the NIH is roughly 5%, and into the NIDCR, even less—close to one eighth of a percent. “So, in terms of thinking about return on investment, one of the best investments that any of us can make is in dental research and technology,” Slavkin asserts.

Peer Review & Information Transfer

Once research has been completed and the questions are answered, the knowledge gained from experimentation and observation must undergo a peer review, Fox emphasizes. This can be accomplished through various publications and dental meetings, including those sponsored by the IADR/AADR.

Finally, information transfer is necessary to translate the research into chairside application, he says. To this end, the IADR—established in 1920 as a non-profit organization that currently has more than 11,000 active individual members worldwide—facilitates the communication and application of research findings.¹ Similarly, the AADR—the US division of the IADR that currently has more than 5,000 individual members and 100 institutional members within the US—endeavors to increase opportunities for scientific exchange and enhance science transfer to scientific and professional societies, educators, clinicians, and the public.²

Lawrence Tabak, DDS, PhD, the current and seventh director of the NIDCR, says that as dental practice becomes increasingly evidence-based, general dentists should continue to expose themselves to the latest research findings. Doing so will enable them to remain in a position where they can provide the very best treatment for each of their patients.

But, as DePaola points out, it takes an average of 15 or more years for what is studied to develop from its early stages of discovery to translation into practice. Ultimately, translation is really affected through the education of dental students and practitioners, during which they are shown that new technologies and techniques will benefit patient care, he says.

“Dentists, in many ways, have been selective adopters of new technology, and some of the biological approaches to dental medicine have been slow to be incorporated into day-to-day practice,” DePaola admits. “When you can demonstrate an economic incentive that allows the research to be applied to daily practice, then it will be applied and utilized quicker than something that is more esoteric.”

According to Tabak, the translation of research into everyday practice is a challenge not only for dentistry but for all medical research. Information transfer to professionals and the public—through literature, association meetings, and the NIDCR’s Web site—is key to ensuring the ready adoption of innovative treatments, techniques, and preventive measures.

Gerard Kugel, DMD, MS, PhD, the associate dean for research at Tufts University School of Dental Medicine, credits the NIDCR with making a concerted effort to communicate with practicing dentists about the research that is taking place and how it stands to benefit the profession. This is important, he says, because government funding for research efforts is ultimately dependent upon the lobbying efforts put forth by constituents who can convince legislators of the value of dental research.

To facilitate the translation and communication process, the NIDCR recently embarked on an ambitious experiment by launching a series of Practice-Based Research Networks. Three 7-year grants, totaling $75 million, were awarded in March 2005 to establish these networks, each of which will investigate with greater scientific rigor everyday issues in the delivery of oral health care.³ The impetus behind the networks is the frequent lack of research data to guide treatment decisions in the dentist’s office.³

The Practice-Based Research Networks that were established are Practitioners Engaged in Applied Research and Learning (PEARL) Network, which is administered by the New York University College of Dentistry; the Dental Practice-Based Research Network (PBRN), administered by the University of Alabama at Birmingham; and the Northwest PRECEDENT, administered by the University of Washington.³ Each regional network will conduct approximately 15 to 20 short-term clinical studies over 7 years, comparing the benefits of different dental procedures, dental materials, and prevention strategies under a range of patient and clinical conditions.³ The networks will also perform anonymous chart reviews—as permitted by the Health Insurance Portability and Accountability Act (HIPPA)—to generate data on disease, treatment trends, and the prevalence of less common oral conditions.³

“There are several hundred practices throughout the country that are now linked together that will be used to address specific research questions that would be best answered in a real world environment, in actual dental practices around the country,” Tabak explains. “An ancillary opportunity here is to determine if research conducted in a practice environment will be more readily adopted by a practitioner.”

A New ADA Initiative

A tell-tale sign regarding whether or not this type of research—at least when it is product focused—is beneficial to practitioners may come when the ADA officially introduces its new ADA Professional Product Report (PPR). Established last year by the ADA’s Council on Scientific Affairs, the PPR is intended to provide ADA members with comprehensive dental product information that is scientifically sound, clinically relevant, and unbiased.⁴

The PPR will offer ADA members quarterly reviews of products in three dental categories. These products will be evaluated by ADA member dentists who volunteer to join the ADA Clinical Evaluator Panel and offer a few hours each month to provide the Council with their feedback on the products they’ve evaluated in terms of how they actually perform in clinical practice.⁵ As of February of this year, approximately 850 ADA members had joined the ADA Clinical Evaluator Panel.⁴

“This is a very important form of research,” explains Kugel. “This type of ‘consumer’ evaluation of products that clinicians may want to use in their practices is immediately relevant because it’s research information that they’re going to put to use right away.”

¹ www.dentalresearch.org/media/index.html

² www.iadr.org/about/aadr/mission.html

³ www.nidcr.nih.gov/Research/Extramural/ClinicalResearch/
GeneralPracticeBasedResearchNetworks

⁴ Garvin J. Professional Product Review offers ‘sneak peak’ in ADA News. February 20, 2006. www.ada.org/prof/resources/pubs/adanews

⁵ Crozier S. Making informed choices. New publication spotlights clinical input from dentists, ADA laboratories; offers buyer's checklist. August 23, 2005. www.ada.org/prof/resources/pubs/adanews

SIDEBAR 3

Adapted with permission from Christopher Fox, DMD, DMSc, executive director of the International and American Associations for Dental Research.

Manufacturers: The Other Supporters & Scientists in Dental Research

When considering the landmark achievements that dental research has made possible within the profession, the contributions from the industrial—or manufacturing—side of the profession cannot be overlooked. Like the more “puritan” biological-based discoveries, research developments and product innovations from manufacturers have changed the practice of dentistry throughout the years.

Product developments, for example, have enabled treatments that are not only functional but also esthetic. Additionally, whereas aggressive removal of tooth structure to accommodate restoration placement was once the norm, modern materials resulting from manufacturer developments enable more conservative treatment approaches. Innovations in implants and the interfaces surrounding the tissues, as well as the abutments, have significantly improved the predictability and acceptance of this treatment modality. Products, equipment, and materials have been introduced to clinicians and laboratories to increase efficiency without sacrificing efficacy.

“Every new concept or new product comes from research, and the thing to remember about research is that it is conducted by individuals in their office environments, researchers and clinicians at dental schools and specialized research institutes, and last but not least, by the dental product manufacturers themselves,” explains Tony Volpe, DDS, MS, vice president of scientific affairs for the Colgate-Palmolive Company. “Although concepts may come from other sources, it’s a general rule that product development research and following through to an actual finished product and application is conducted by industry.”

According to Andrew Lichkus, PhD, chief technology officer for DENTSPLY, the legacy of dental research—including that which has been conducted by dental product manufacturers—is the significant number of researchers from several disciplines dedicated to improving the standard of care through the clinical interface of the dental profession. Their efforts provide products that enhance care when placed in the hands of dental professionals, whether the application is the diagnosis, prevention, or treatment of disease.

“There are tremendous scientists that work for industry,” remarks Christopher Fox, DMD, DMSc, executive director of the International and American Associations for Dental Research (IADR/AADR). “Dentists should view the science that is happening in the dental industry as just as important as the research taking place at academic institutions.”

From Concept to Patient Care

Like the wonderment that launches traditional scientific investigations, the ideas that ignite product research and development come from a variety of sources. Some are internal to the company, others external. They come from members of the dental profession, based on an understanding of day-to-day practice needs and the direction in which dentistry is heading. There may be seminars, focus groups, or market research studies that provide input to the product development process.

“Some ideas come from academia, individual inventors clearly have a role, and now—more prominently—start up biotechnology companies may do initial proof of concept research,” explains Robert Gerlach, DDS, MPH, principal scientist in worldwide clinical investigations for Procter & Gamble. “Those groups may partner with larger organizations for further development, and some ideas may also come from policy making, regulatory issues, or even emerging health awareness.”

Lichkus sees manufacturer efforts as the translation mechanism for the commercialization of internal (company) and external ideas from clinical professionals, the scientific and engineering community, or other researchers outside of dentistry that could potentially improve dental treatment outcomes. There are potentially numerous technologies and innovations outside the dental industry, he emphasizes, that can also play a role in solving dental problems.

“Industry has recognized over the years that basic research—without some clearly defined profitable goal—is risky and expensive,” explains Tony Winston, a research fellow with Church & Dwight. “Industry is only profitable if it has a product to sell, and academic knowledge has its greatest value when it is applied to solving problems in the public domain. So, companies tend to support basic research done by universities or other non-profit organizations in areas of their interest.”

Manufacturers develop concepts that they need to know are valid and can be applied to the general market, a need that Ed Shellard, DMD, president of Kerr Corporation, believes motivates dental manufacturing to support research at the university or non-profit level. There is general agreement, he says, that there needs to be a collaborative effort between university-based or government-supported research centers and manufacturing.

“Developing a product today is a very complex process that requires several years, from idea conceptualization to creation of prototype products, as well as the upscaling process and validation studies,” explains George Tysowsky, MPH, DDS, vice president of technology for Ivoclar Vivadent, Inc. “These sequential undertakings require significant efforts by chemists and engineers throughout the product development process, followed by conscientious studies by in-house and/or independent researchers to validate the efficacy of the final products.”

And the efforts are significant. Volpe explains that within the manufacturing environment, there are people who devote themselves to developing basic concepts and testing those early concepts, as well as others who secure feedback on those concepts from users. From there, the basic research is conducted that leads to product development and the creation of prototype models, after which patents are filed and funding is secured to enable the completion of other necessary processes. Those include safety and efficacy testing, regulatory and professional agency approval, and a host of other activities that all lead to product delivery.

“Industry plays a vital role in all aspects of research to develop products that enhance the practice of dentistry,” Volpe asserts.

The reliable manufacturers involved in establishing testing protocols choose to do so to ensure that those products are successful and can perform up to the expectations of the final clinical environment, Tysowsky explains. The clinical trials or laboratory studies that are required are very comprehensive.

Because government funding has, in recent years, focused more on infrastructure development in dental schools and basic science, research application has often been left to manufacturers, Gerlach explains. In this regard, randomized clinical trials represent the highest form of evidence of safety and efficacy, he says, and these usually occur late in the research and development process, after the bench research has been completed.

“This is high-risk, high-reward research that is often sponsored by industry, often in collaboration with various research organizations,” Gerlach says. “The research is extensive and highly regulated, and it results in the evidence that we, in dentistry, have come to embrace or reject depending upon what it shows with respect to new techniques, methods, materials, or products.”

Collaboration & Funding

“Quality research is very costly,” Tysowsky emphasizes. “There are multiple millions of dollars involved, obviously from the funding of research staff, in-house testing, external in vitro testing, and also clinical trials. Much of that burden does rest on the manufacturers.”

Although some support may be received through government agencies such as the National Institute of Dental and Craniofacial Research (NIDCR), oftentimes the burden of funding research related to specific product developments rests with the manufacturers, Tysowsky says. But manufacturers can’t do it all alone, and outside research and validation is key to ensuring successful clinical outcomes. It’s a two-way street.

“Truly translating university-based research findings into applications for day-to-day practice requires commercialization,” Shellard says. “Without collaboration among manufacturers, universities, and clinicians, that research—and its resulting products—wouldn’t otherwise get to into the hands of clinicians or benefit the public.”

Within the manufacturing world itself, the funding issues companies face are not unlike those of universities or government-supported centers. There is competition for money to support the research of a novel idea. However, in addition to the basic research, manufacturers are faced with the burden of proving two additional requirements, Gerlach explains. First, the company must demonstrate that it can obtain a proprietary or patent position. Second, it must show that the idea has the potential to eventually be profitable.

Overall, like the research taking place in academic environments, manufacturer research also involves selective resource allocation, but across the entire product development process of idea generation, concept formation, prototype development, and validation, including clinical studies, Lichkus says. To routinely introduce products which meet the current and future needs of dental professionals, he notes that collaboration between a broad spectrum of clinicians, scientists, engineers, and marketing professionals is required in a successful and innovative product pipeline.

“Creativity and perseverance are also critical characteristics of successful research, and these effectively intangible resources must be stimulated and harnessed as well,” Lichkus believes. “So, if I were to look at research overall, I would say that we allocate significant resources, time, and effort to identify technologies and develop effective, innovative, reliable, and safe products which adequately address the needs of dental professionals.”

Partnering for Tomorrow’s Potential

Like their university and research institution counterparts, members of industry are exerting significant efforts toward the development of salivary diagnostics, enhanced caries detection devices, and methods for assessing systemic disease. According to some, the era of single-tooth treatment is gone, and manufacturers are challenged to support clinicians as the profession moves into a future that encompasses comprehensive care.

To satisfy current and future expectations, dental manufacturers are looking for partners at universities and research centers for testing and validation as they drive new technologies and new areas of developments. Like the profession as a whole, manufacturers are hopeful that eager and interested people will pursue dental research in order to maintain a standard of excellence for the future.

SIDEBAR 4

Fast Forward— Tomorrow’s Dentistry Will Be Based on Today’s Research Agenda
The dental profession is on a precipice of a number of findings that have taken place in the “medical” world, as well as other technology-related fields, for which applications to dentistry are now being explored. As a result, the future legacy of dental research will lie in areas related to personalized medicine, regeneration vs restoration of tooth structure, and genetically based, early diagnosis and prevention of oral diseases, among others.

Presently contributing to the future is the Human Genome Project (HGP), a 13-year undertaking completed in 2003 that was coordinated by the US Department of Energy and the National Institutes of Health (NIH) at a cost of approximately $3 billion from start to finish.¹ Its goals included identifying all of the approximately 20,000 to 25,000 genes in human DNA and determining the sequences of 3 billion chemical base pairs that make up human DNA. Because genes carry information for making all proteins required by organisms—proteins that determine how well an organism can fight infection, among other things—insight into DNA variations has implications for health care, including dentistry, in terms of diagnosing and treating a variety of disorders.²

What does this mean for dentistry? Consider that any biomarker that can be found in blood can also be found in saliva. They’ve always been there, explains Christopher Fox, DMD, DMSc, executive director of the IADR/AADR, but until recently, the tools weren’t available to detect the very small amounts that are present in saliva.

“There is very exciting research taking place at UCLA looking at seven biomarkers for oral cancer,” Fox elaborates. “A methodology has been developed to isolate these biomarkers, as well as a diagnostic test with very high sensitivity and specificity for oral cancers, so this is going to be a very positive step toward early diagnosis and treatment of a devastating condition.”

According to Lawrence Tabak, DDS, PhD, director of the National Institute of Dental and Craniofacial Research (NIDCR), the Institute is constantly looking for opportunities to borrow, enhance, and integrate knowledge from biomedical and technological research. It’s amazing, he says, how creative people can develop implications for dentistry from seemingly unrelated research findings.

“For a number of years, bioengineers have been miniaturizing labs on a chip,” he explains. “Bioengineers, working with oral biologists, quickly realized that a lab on a chip can be adapted for use in the oral environment, and from that was born the salivary diagnostics program that the NIDCR sponsors.”

Super Saliva

That program includes the work of dentist/scientist Dr. David Wong from the UCLA School of Dentistry. With support from two, four-year awards from the NIDCR, Wong is establishing the UCLA Collaborative Oral Fluid Diagnostic Research Center and the Human Salivary Proteome Project (www.hspp.ucla.edu). Through the Oral Fluid Diagnostic Research Center, Wong is developing nanotechnology-based microsensors—so called “labs on a chip”—for translational applications for molecular diagnostics of oral cancer and oral pathogens based on saliva.³

“The ability to miniaturize and computerize a variety of hand-held point-of-care devices for measuring wellness, quality of life, disease, and progression of treatment will change the practice of dentistry and medicine in the United States and in the industrial countries of the world,” predicts Harold Slavkin, DDS, dean of the University of Southern California School of Dentistry.

The Human Salivary Proteome Project—also at UCLA—is endeavoring to decipher the entire catalogue of proteins found in human saliva.³ It is one of three groups nationwide that are decoding the entire proteome of saliva, Tabak says. It is proceeding rapidly, and the first draft is expected to be available in the first quarter of 2007.

Combined, the saliva research could lead to the salivary gland being used as a general bioreactor to replace proteins that are missing from an individual. For example, in the case of diabetes, gene therapy could be used to “trick” the salivary gland into producing insulin, Tabak explains. Or, if an individual lacked sufficient growth hormones, the salivary gland could be manipulated into producing what’s needed.

“We are awaiting approval from the FDA to actually begin our human trial for the purpose of using gene transfer in the salivary glands to correct the destruction that occurs during radiation,” Tabak shares. “This is happening real time.”

A Caries Vaccine

Fox also notes that probably within the next 20 years, a caries vaccine will be a reality. “We have the science, so it should certainly be possible to produce a vaccine,” he says. “It’s a matter of getting the right research funding behind it, as well as the right commercial model.”

At The Forsyth Institute in Boston, current research is refining a vaccine that intercepts the accumulation of S mutans on the teeth to prevent decay in animals and delay infection in adults. The Forsyth Institute—one of two organizations worldwide that has placed a major emphasis on developing this type of vaccine for children—is refining this vaccine so that it can be given to children before the bacteria can colonize in their mouths.⁴

“We have on the horizon the potential for vaccines for dental cavities, which of course would make a monumental difference in preventing dental diseases—particularly caries—in populations that don’t have very good access to care,” says Dominick DePaola, DDS, PhD, The Forsyth Institute’s president and chief executive officer.

Tissue Engineering & Stem Cells

Rather than replacing lost tissue—whether as a result of dental caries or periodontal disease—with artificial materials, tomorrow’s dentistry will focus on getting the body to reproduce those lost tissues, Fox says. Tissue engineering and stem cell research is taking place at a number of different institutions for this purpose. In particular, NIDCR-supported research is currently addressing stem cell biology using cells derived from dental pulp, as well as from bone marrow, as a means to replace lost tooth structure and bone.

“In the next decade or two you will find that stem cells and tissue engineering are going to revolutionize what we currently put under the heading of restoration of form and function,” Tabak says. “I have no doubt that things like pulp capping and restoration of small carious lesions will be augmented by tissue engineering and stem cell-based approaches.”

¹ www.ornl.gov/sci/techresources/Human_Genome/project/budget.shtml

² www.ornl.gov/sci/techresources/Human_Genome/home.shtml

³ www.cf.research.ucla.edu/cfdocs/faculty

⁴ www.forsyth.org

SIDEBAR 5

The Inside Look FROM...

The staff and publishers of Inside Dentistry gratefully acknowledge the time, insight, and thoughtful comments shared by our interviewees, without which this inside look at the legacy of dental research would not have been possible. The following individuals, all well-respected throughout the dental research arena and industry at large, made invaluable contributions to this presentation.

Academia

Gerard Kugel, DMD, MS, PhD
Associate Dean for Research
Tufts University School of Dental Medicine
gerard.kugel@tufts.edu

Harold Slavkin, DDS
Dean
University of Southern California School of Dentistry
slavkin@usc.edu

Research Institutions/Associations

Dominick DePaola, DDS, PhD
President & Chief Executive Officer
Th