NIDCR Research: Changing the Face of Dentistry

As hundreds of researchers across the country work to unlock the secrets of a variety of complex oral and dental diseases, they are engineering a quiet revolution that may lead to better patient outcomes and, perhaps, changes in the way dental professionals learn and practice.

Harold C. Slavkin, DDS, director of the National Institute of Dental and Craniofacial Research for the past five years, recently testified before the House Appropriations Committee to justify NIDCR’s funding request for 2001 to ensure that work continues.

Meanwhile, as NIDCR funds studies that will shape the future of dentistry, the U.S. surgeon general’s office is set to release its first-ever report on the current state of oral health in America. These two events are focusing national attention on dental health.

With many advances on the horizon, and with new thinking about how to provide oral health services in the future, dentistry in the coming decades will change. How much and how quickly nobody knows, but Slavkin recently shared his intriguing ideas with CDA Journal.

"Dentistry was invented as a surgical specialty about 150 years ago," says Slavkin, whose institute funds much of the country's dental-related research. "But because of advances in microbiology, immunology, biochemistry, molecular genetics, and public health, there will be the opportunity for the dental surgeon to diversify into working smarter, maybe getting better and more predictable outcomes. This is what science can do."

Slavkin testified Feb.17 before the House Appropriations Committee to justify NIDCR’s request for $263.1 million in funding for the 2001 fiscal year, an increase of $14.1 million over this year’s budget. Those funds will be used to improve the public’s health through research in genetics and in systemic diseases and disorders affecting craniofacial tissues and structures.

Slavkin says NIDCR operates against the background of a large social canvas that represents the driving force behind all its research efforts.

"One of the major themes that we have been sharing with Congress and others is driving the future of dentistry, and that is the American public," Slavkin says. "When you think of the demographics of the population, their changing pattern of disease, and the health disparities that exist, those become drivers for the future of dentistry."

According to Slavkin, researchers this spring will complete the description of the human genome in draft form. By 2003, when it will be fully described, Slavkin said it will provide a readily accessible knowledge base that can be "mined" for many insights into the human condition.

"There will be more gene-based diagnosis, therapy, and drugs," he says, "and more biomaterials than ever before in the history of mankind. All of this will impact the practice of dentistry in various ways."

Slavkin also says that in the future the use of saliva will be commonly used as a diagnostic tool, and more innovative ways of imaging will come into play, such as using MRI instead of X-rays.

"Also, the idea of solo practice may evolve into more of a need for cross-thinking among health professionals," he says. "For example, if I’m interested in children’s oral health, I may end up in an office with a pediatrician, a speech therapist, and a child psychologist to create a one-stop shopping experience for parents."

Slavkin says that the research is also pointing to a process where dental professionals will work cooperatively with other health providers to provide the best possible patient outcomes.

"The research is indicating the need for cross and multidisciplinary approaches to diagnosis and treatment of human disease," he says. "But we want individualized treatment and care, so there will always be a tension between the collective and individual approach, and I think that’s healthy."

According to Slavkin, dentists and auxiliaries will need to prepare themselves to practice in the future, where the population of people aged 75 and older will be a significant factor.

"They present opportunities to dentistry that are different than what we were trained to do currently or 20 years ago," he says. "So as a dentist in California, I would want to select continuing education courses that address medical emergencies in dental offices, and the diagnosis and treatment of patients who are medically compromised."

Slavkin says he would want some courses in the principles of internal medicine in order to develop better medical understanding of patients and their cultural diversity, a factor that is increasingly important in California.

"I may also want to figure out how I can be more cost-effective, so I may have to delegate some responsibilities to have a team working with me so I can make a living and do good at the same time," he says.

Dental schools will also have to begin dealing with the future of dentistry.

"We have to educate and train students for where dentistry will be practiced in the future, and that means more emphasis on health promotion, disease prevention, diagnosis, and smarter and more cost-effective treatment," says Slavkin, who will leave NIDCR in July to become the dean of the School of Dentistry at the University of Southern California. "We also have to be aware to pay attention to the outcomes of treatment. I think that’s part of where we are headed in the next 10 to 20 years."

Fluoride/Bone Study Results Differ

While a study from Britain indicates that drinking fluoridated water does not increase the rate of hip fractures, another in Finland finds that it does, but only in women.

Researchers at the University of Southampton studied 514 hip fracture patients in the English county of Cleveland, where water is fluoridated in some communities and not in others, and compared them to 527 control subjects without hip fractures.

The results, published in the Jan. 22 issue of The Lancet, show that the chance of fracturing a hip was the same for those who drank water containing fluoride in concentrations of about 1 ppm as for those whose water contained less.

However, a study from the National Public Health Institute in Kuopio, Finland, had different conclusions when its study results were analyzed by gender.

The researchers studied a cohort of 144,627 people born from 1900 to 1930 who had lived in the same rural location at least from 1967 to 1980. The median fluoride concentration in their well water was 0.1 mg/liter. No association was observed between hip fractures and estimated fluoride concentration in the well water in either men or women when all age groups were analyzed together. However, the association was modified by age and gender so that among women aged 50 to 64 years, higher levels increased the risk of hip fractures. The study was published in the Oct. 15, 1999, issue of the American Journal of Epidemiology.

Clinical Trials Information Is Available on the Web

The National Institutes of Health has launched the first phase of a consumer-friendly database, ClinicalTrials.gov, with information on more than 4,000 federal and private dental and medical studies involving patients and others at more than 47,000 locations nationwide.

ClinicalTrials.gov provides patients, families, and members of the public easy access to information about the location of clinical trials, their design and purpose, criteria for participation and, in many cases, further information about the disease and treatment under study. There is also contact information for individuals responsible for recruiting participants for each study.

"Through this new database, NIH offers up-to-date information on promising patient-oriented research on hundreds of diseases and conditions," says acting NIH Director Rugh L. Kirchstein, MD.

A recent search of the site showed 96 trials recruiting for patients for oral and dental studies, including trials on dental caries, periodontal disease, and xerostomia.

ClinicalTrials.gov is a confidential Web site. No registration or personal identification of any kind is required. People who search the site will not be contacted by the sponsors of clinical trials or anyone else.

Children with Down Syndrome Have Higher Perio Risk

Severe periodontal inflammation is often seen in children with Down syndrome.

A study released in the February issue of the Journal of Periodontology found that various periodontal bacteria colonize in the early childhood of people with Down syndrome. And, P. gingivalis increases in prevalence with age in those with Down syndrome, playing an important role in the onset of perio disease.

"We suspect that several factors make people with Down syndrome susceptible to periodontal bacteria colonization and dangerous plaque formation," says the study’s lead researcher, Atsuo Amano, DDS, PhD, assistant professor in the Division of Dentsity for the Disabled at Osaka University in Japan. "They have less immunity, experience deterioration in the mouth due to premature aging, and often have inadequate oral hygiene. In addition, they are apt to have various congenital deformities in the mouth, such as short teeth, a small oral cavity, displaced and missing teeth, defective tooth enamel and fragile gingival tissue."

While children with Down syndrome often exhibit inflammation of the gum tissue, researchers on this study believe they maintain enough immunity to protect them from severe periodontal destruction until they reach their late teens or early 20s.

"Our investigation found that significant periodontal breakdown starts around age 20 in about 60 percent of individuals with [Down syndrome]," Amano says.

However, Amano stresses that proper oral hygiene in these children can make a significant difference in warding off periodontal disease and protecting the teeth.

"Plaque control is the most effective strategy in preventing periodontal disease in the [Down syndrome] population," he says.

Amano recommends that dental professionals instruct parents of Down syndrome children in proper brushing and flossing techniques and in use of tools that may make those tasks easier, such as electric toothbrushes.

Asthma Increases Caries Risk in Children

Children with asthma are at an elevated risk of developing dental caries and other oral pathologies, according to a study published in the September 1999 Texas Dental Journal.

The study, by Michael Milano, DMD, examined the patient charts of 179 asthmatic children and 165 healthy children, ages 2 to 13 years, in treatment at the pediatric dentistry program at the University of Texas Health Science Center. The selection of study participants was based on seven criteria requiring them to:

* Have a non-asthmatic sibling in the stated age range, being treated at the university. * Have a medically confirmed diagnosis of asthma.

* Be using medication to treat asthma.

* Be free of other serious medical conditions.

* Not be on a fluoride supplement.

* Have fair to good oral hygiene at every visit.

* Have no history of baby bottle tooth decay.

All the patients’ charts were examined and scored for decayed, missing, and filled teeth in primary dentition (dmfs, dmft) and permanent dentition (DMFS, DMFT). While more than one dental resident was involved in the scoring, one faculty member reviewed all the charts in an effort to standardize the scores. After examining the data, Milano reached these conclusions:

* Before the eruption of any permanent teeth, asthmatic children have significantly higher dmfs and dmft scores than non-asthmatic children.

* In the mixed dentition, asthmatic children have significantly higher DMFS scores and continue to have significantly higher dmfs scores than non-asthmatic children.

* No significant difference was found in the dmft and dmft (JMT: Is the bold-faced reference correct?) scores between asthmatic and non-asthmatic children in the mixed dentition.

* In the mixed dentition stage, asthmatic children may not have more teeth involved in the caries process, but those involved may be more severely affected.

* A preventive program for each asthmatic child should be instituted to minimize the effect the disease has on the caries rate.

High Anxiety Need Not

Be Part of Bitewing Use

Taking bitewing radiographs of children can be a trying experience for both the children and the dental staff, according to an article in the September-October 1999 Journal of Dentistry for Children.

Drs. Tarja Kaakko, Christine A. Riedy, Yukie Nakai, Peter Domoto, Philip Weinstein, and Peter Milgrom contributed to the article.

General guidelines require that posterior bitewings be taken in all new child patients, at six-month intervals for high-risk children and every one to two years for low-risk chilren, the researchers note.

Although many textbooks describe the technical aspects of taking radiographs of children’s teeth, they provide little guidance on behavioral management of children during the procedure. Use of effective behavior management prevents problem behaviors and enhances cooperation in children, and a good first experience means children are less likely to avoid future dental treatment, the authors write

They offer these behavior management tips:

* Building rapport is the most important part of treating children and helps create an environment that feels friendly and safe. Acknowledge a child’s presence as soon as he or she arrives and communicate at the child's eye level.

* Conduct a tell-show-do session to familiarize the child with the situation. Explain that some "tooth pictures" are needed and how the procedure will feel, how long it may last and what sounds will be experienced. Explain that the thyroid collar is a "special jacket" used when taking tooth pictures, and tell the child that the X-ray cone needs to be very near, perhaps even touching the cheek. Be sure to explain what the film holder’s purpose is and that the child will be alone in the room when the radiograph is taken.

* Positive reinforcement throughout the procedure, including thanking and praising the child, is very important. Even if the first attempt is not successful, keep the positive reinforcement flowing to reassure the child and build trust.

* Modeling can be used so the child can observe someone else going through the procedure. They can see in advance what the procedure requires and that the "model" tolerated the experience. Reluctant children will see the film holder in someone else’s mouth and benefit by that.

* Dentists can imbue a sense of control in the child by listening to his or her feelings. Don't ignore a child's reporting of difficulty during the procedure. Instead, make sure the child understands the dentist is aware of the difficulty and will make needed changes, and then thank the child for reporting the difficulty.

Web Watch: Dental Auctions

The top auction Web sites have a variety of dental-related material for sale. Recent offerings included:

* New dental equipment -- including handpieces and endodontic units.

* Collectibles -- including an antique dental chair, vintage porcelain tooth sets, and a vintage shirt for a dental bowling team.

* Educational materials -- including continuing education courses and vintage textbooks.

* Toys -- including dental theme Smurf figurines and French-speaking dentist Barbie.

Three top online auction sites:

http://www.ebay.com/

http://auctions.yahoo.com/

http://www.amazon.com/

Upcoming Meetings

2000

May 5-7 Periodontal Medicine: Clinical and Practical Implications, Washington, D.C., (312) 573-3213, www.perio.org.

May 15-20 World Biomaterials Congress and Exposition, Kamuela, Hawaii, (612) 543-0908

June 12-13 "The Face of a Child" -- Surgeon General’s Conference on Children and Oral Health, Washington, D.C., (301) 588-6000, www.nidcr.nih.gov/sgr/children/children.htm

July 26-28 Pacific Northwest Dental Conference, Seattle, www.wsda.org

July 30-Aug. 2 Congress of the International Society for Lasers in Dentistry, Brussels, Belgium, +32 2 648 80 59.

Aug. 14-16 Association of Philippine Orthodontists National Congress, Manila, Philippines, (632) 890-2824

Sept. 15-17 CDA Scientific Session, San Francisco, (916) 443-3382, Ext. 4470

Sept. 17-20 American Academy of Periodontology Annual Meeting, Honolulu, www.perio.org

Oct. 14-18 ADA Annual Session, Chicago, (312) 440-2500

Oct. 26-28 American Society for Dental Aesthetics, Millennium International Conference, San Francisco, (800) 454-2732, www.asdatoday.com.

Nov. 29-Dec. 2 Le Mondial du Dentaire, Paris, http://www.fdi.org.uk/calender/index.htm

2001

May 4-8 Australian Dental Congress, Brisbane, +61 (0) 7 3369 0477

To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.