Global Health Nexus, Fall 2000

Seeing the Future

In envisioning the future of oral health and dental practice 30 or more years from now, the contributors to this feature— each a recognized authority in his or her discipline—have displayed the imagination and vision that one expects of respected clinicians and scientists. We hope that their attempts to capsulize the future of dentistry will provide you with substantial food for thought. But as one of our visionaries, Dr. Irwin Mandel, cautions, “He who looks into a crystal ball is destined to dine on ground glass.” We leave it to you to match your predictions against those of our experts and to decide what’s credible and what’s edible.

Dr. Dominick P. DePaola

The dental profession will be totally integrated into the practice of medicine. There will also be a reimbursement system for health care that is not discriminatory just because the word dental precedes medicine.
Geographic boundaries imposed by state boards will be eliminated, making the practice of medicine/dental medicine national in scope.
Rather than surgical and mechanical tissue manipulations to repair or fill either soft or hard tissue defects, the appropriate use of genetic tissue engineering will be the preferred approach and the basis for continuing clinical practice.
Minimally invasive technologies powered by advanced information systems will greatly reduce unavoidable trauma, pain, and recovery time associated with surgical protocols, relegating dental phobia to the historical archives.
We will see an integrated health professions education system, rather than independent schools of medicine, dentistry, nursing, pharmacy, and the like.
The monoliths of medical/dental schools and libraries will be replaced by distributed information systems and community-based clinical, educational, and outreach “centers of excellence.”

Dr. DePaola, a 1969 graduate of NYU Dentistry, is president and CEO of The Forsyth Institute. A past-president of the ADEA, a member of the National Advisory Council of NIDCR, and a former dean of three dental schools, Dr. DePaola's provocative points of view have enriched dental education, research, and practice for decades.

Dr. Robert S. Ledley

“Prediagnosis” based on genetic characteristics of individuals will anticipate the possible occurrence of pathogenesis and enable individualized preventive treatments.
Molecular motors, set in motion by the dentist, will be used to perform dental procedures and craniofacial reconstruction mechanics, including reshaping mandibles and other facial structures.
Research on stem cells will allow tissues to be grown to replace epithelial structures, both of soft tissues, such as skin and mucous membrane, and hard tissues, such as bones and teeth.
With respect to bone, the dentist will be able to use a special camera to take a stereo image of broken or deformed craniofacial bones and then automatically compute the shape to be reconstructed. Using advanced methods, the shape of the structural components will be reproduced in a hard, porous matrix into which the replacement tissues will grow and replace the matrix.
Food additives will be developed that will entirely prevent decay and periodontal disease, keep teeth white and shiny, keep the periodontal membrane healthy, and keep the bone support of teeth strong and intact. As a result, tooth loss will occur only through accidents.

Dr. Ledley (NYU Dentistry Class of 1948), a professor of physiology and biophysics and of radiology at Georgetown University Medical Center, is best known for developing the first whole-body computerized tomography (CT or CAT) machine. In 1999, he received the NYU Distinguished Alumnus Award. He has also been awarded the National Medal of Technology, the nation’s highest honor for technological achievements.

Dr. Irwin D. Mandel

Edible transgenic plants (bananas, potatoes, etc.) containing specifically designed “plantabodies” against mutans streptococci will join increasingly effective fluoride formulations plus remineralizing agents in a variety of products to prevent virtually all dental caries.
Specific antibacterial agents derived from the functional domains of protective proteins in saliva and other mucosal fluids will prevent the initiation of periodontal disease. Teeth will remain firmly rooted throughout life.
Gene therapy for restoring function for salivary glands incapacitated by disease or radiation will be joined by “epithelial gene” therapy for treatment of oral mucous membrane disease using genetically altered cultured epithelial cells from host biopsies.
Chemical sensors employing nano-technology will make it possible to use a drop of saliva for diagnosis of oral and systemic diseases, risk management, and genetic screening.
Despite dental school efforts to integrate the restorative/aesthetic and biological aspects of teaching programs, with a growing number of dentists utilizing a broad array of diagnostic, preventive, regenerative, and genetically related procedures, there will be increasing overlap with medicine, and “turf wars” can be envisioned. Some things never change.

Dr. Mandel is a professor emeritus at Columbia University School of Dental and Oral Surgery and the first person to receive the Gold Medal for Research awarded by the American Dental Association.

Dr. Richard F. Mascola

The extent to which dental practice remains autonomous 25-50 years into the future will depend upon what all of us in the profession do now to uphold the sanctity of the doctor/patient relationship and the ability of dentists to follow their best professional judgment.
It is predictable that a high-quality reference genome sequence will be completed by 2003 or sooner, bolstering our understanding of how genetics influences disease development and leading to the discovery of new dental treatments.
The completion in 2001 of an intensive, two-year ADA-sponsored Future of Dentistry study will provide a blueprint to ensure the continued strength and effectiveness of the dental profession.
The ADA will play a leadership role in providing members with information technology tools to help them thrive and prosper in the electronic information age.
The ADA’s Web site at www.ada.org will become an increasingly strong and effective link with members. The surge in usage will become especially dramatic as today’s dental students enter practice and make the ADA Web site their leading source for services and information.
Full ethnic and racial diversity in the profession and in organized dentistry remains a goal. The ADA will foster activities to achieve this goal.

Dr. Mascola (NYU Dentistry Class of 1968) is immediate past-president of the American Dental Association. He has been a pivotal force in energizing young dentists about the value of organized dentistry and a stalwart in ensuring that all treatment decisions remain the exclusive purview of the dentist and patient.

Dr. Lawrence H. Meskin

Mega dental education and research centers will supply the major training and research requirements for the dental profession. The present dental schools will cease to exist except as clinical sites for specialty training of residents and as centers for referral and treatment of difficult cases.
Most nonclinical D.D.S. instruction will take place off-site using computer-generated educational materials. The subsequent efficiencies will eliminate student debt and prevent faculty shortages.
As dentists assume major roles as diagnosticians and treatment planners, they will provide primarily specialty care. The remainder of hands-on treatment will be provided by technicians under the direction of these “super dentists.”
Microcomputer chips inserted in the periodontal sulcus will maintain periodontal health, prevent dental caries, etc. These chips will activate robots which, on command, will clean out the dental sulcus at predetermined intervals.
Legislation providing dental care for the elderly, supported through Medicare, will become a reality early in the 21st century, due to the political clout brought to bear by the “baby boomer” generation.
With the passage in 2015 of the Federal Right to Practice Anywhere Act—following a successful class action suit brought by dentists—licensure, state dental boards, and freedom of mobility will cease to be issues.

Dr. Meskin is a professor at the School of Dentistry of the University of Colorado Health Sciences Center and editor of the Journal of the American Dental Association. His perceptive, incisive editorials have constantly challenged the profession.

Dr. Diane Rekow

Tissue-engineered materials to regenerate hard and soft tissues will be commonplace.
Current radiographic and MRI diagnostic imaging techniques will be replaced with high resolution 3-D, noninvasive, nonhazardous systems capable of imaging and recording both anatomy and function.
Computational biology will provide computer-based models to replace a major portion of the in vivo testing now required for product introduction.
Saliva and crevicular fluid will be a diagnostic and health monitoring fluid. Saliva could likely replace blood as a fluid reflecting the health status of a person.
Smart micropores will be engineered to perform specified functions on command. For instance, selectively permeable membranes around pores could attach to the teeth and release fluoride when bacterial levels reach caries-causing thresholds.
Genomics information will be used to establish which patients are prone to various diseases, permitting clinicians to proactively treat preventable conditions.

Dr. Rekow is a professor and chair of the Department of Orthodontics at the University of Medicine and Dentistry of New Jersey (UMDNJ) New Jersey Dental School. Trained in engineering, dentistry, orthodontics, research, and business, she also directs a major consortium on tissue engineering in New Jersey.

Dr. Sidney I. Silverman

The development of a radiation beam of energy that can slice and/or peel molecular layers of tissue will dramatically reduce the use of the rotary diamond drill and bur, the endodontic broach and file, and the scalpel and currette.
The currently used metals, porcelains, and plastic resins for prosthodontic treatment will be replaced by biochemically and genetically induced orodental and facial tissues.
Current and future generations of dentists nurtured on interactive Internet technology will develop a genetically altered nervous system derived from the neural plasticity inherent in all children’s brains at birth.
Internet-adept dentists will boast genetically improved cognitive components of human brain function with respect to decision making and performing hand-eye skill procedures.
The interactive Internet will instantaneously allow the brains of two or more dentists to join their capabilities for abstract thinking and judgment to exponentially enhance their collective decision making.

Dr. Silverman, a 1937 graduate of NYU Dentistry, is a professor emeritus and clinical professor of prosthodontics at NYU Dentistry and a clinical professor of neurology at the NYU School of Medicine. Dr. Silverman wishes to thank Dr. Freeman Dyson, author of the recently published monograph “The Sun, the Genome and the Internet” for inspiring his predictions.

Dr. Harold C. Slavkin

By 2020, more than 80 percent of the U.S. population will have access to oral health care.
Increased public awareness of the oral complications of systemic diseases and of the relationship between oral infections and systemic diseases will significantly impact “third party reimbursement” for oral aspects of many systemic diseases, including cancers, diabetes, and cardiovascular and pulmonary diseases.
Academic health science centers will offer cross-disciplinary, multidisciplinary education, training, and scientific research programs, resulting in increased hybridizations among the health sciences—dentistry, medicine, nursing, dental hygiene, pharmacy, and physical and speech therapy.
A major shift in national priorities will lead to a new emphasis on health promotion (making and maintaining healthy choices and practices) and risk assessment to reduce disease burdens, especially as related to the many health disparities among segments of the population.
Biotechnology solutions to clinical problems will become mainstream, including highly specific and sensitive noninvasive imaging, the use of saliva as a diagnostic fluid, gene-mediated therapeutics for tissue repair and regeneration, and individualized pharmacogenetics.
Thanks to rapid progress of the Human Genome Project and functional genomics, novel gene-gene and gene-environment understanding will occur, bringing with it profound changes in the ability to assess and manage chronic diseases and disorders.

Dr. Slavkin is dean of the University of Southern California School of Dentistry. He is also the former director of the National Institute of Dental and Craniofacial Research, where he led a remarkable transformation of the institute, making craniofacial health part of mainstream thinking at the NIH.

Dr. Martha Somerman

Preventive and treatment protocols will be based, in part, on individual genetic profiles that reflect information on disease susceptibility.
Biomarkers, obtained from oral fluids and tissues, will be used to identify patients at risk for certain oral and systemic diseases.
Tooth loss will be minimized by the availability of more effective agents and methods for regenerating/repairing tooth structure and supporting soft and hard tissues.
Drilling will become obsolete as lasers and less invasive techniques are perfected.
Annual oral/dental exams will be required for all children K–12. This will address, in part, the disparities in oral health status among various socioeconomic groups.

Dr. Somerman (NYU Dentistry Class of 1975) is a professor and chair of the Department of Periodontics/Prevention/Geriatrics at the University of Michigan School of Dentistry and a highly respected scientist.

Dr. Dennis P. Tarnow

All grafting will be done using cloned cells from each patient. At birth or soon after, a few cells of bone and connective tissue will be harvested and cloned and then stored for use for the rest of the individual’s life.
All fillings, if any are needed, will be made of the patient’s own enamel which was cloned previously.
A vaccine will be used to eradicate caries and periodontal disease.
We will be able to add genetic modifiers to sockets, not only to make them heal faster than normal but also to change the density of the bone that develops.
All drilling for the placement of implants will be done by robotics.
Any periodontal problems that occur will be treated by regeneration, as opposed to repair of the defect. As a result, extractions will become obsolete.

Dr. Tarnow (NYU Dentistry Class of 1972) is a professor and chair of the Ashman Department of Implant Dentistry at NYU Dentistry. His two-year training program in implant dentistry has been attended by dentists from more than 25 countries.

Dr. Ray C. Williams

A specific periodontal risk profile will be created for each patient, which will provide the therapist an appropriate algorithm for managing that particular patient over the short and long terms.
Rebuilding periodontal attachment structures—around teeth that have periodontal disease—will be as simple as a prophylaxis.
Placement of dental implants in all areas of the mouth, regardless of amount and quality of bone, will be easy and facilitated by the use of biological mediators/anabolic cytokines.
Periodontal graduate programs will include considerable training in general medicine and, with time, most programs will offer an M.D. degree as part of the training program.
Dentistry will become more and more a specialty of medicine. The majority of dental training will include the M.D. degree, with increasing numbers of dentists having dual degrees. Eventually the M.D. degree will include the specialty of dentistry.

Dr. Williams is a professor and chair of the Department of Periodontology at the University of North Carolina at Chapel Hill. He is one of the first investigators to have proved that the progress of periodontal disease can be mitigated pharmacologically.