Beyond the drill

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Beyond the drill
Tom Anderson
Employee Benefit News
July 2004

In today's world of gene therapy and noninvasive surgery, dentistry doesn't seem that high tech. When fighting tooth decay and gum disease, dentists still use sharp metal objects to do their work.
But innovations are creeping into the marketplace. Smart fillings and sealants are being designed to release fluoride when threatened by decay. Dental researchers are experimenting with ways to re-grow bone, which could lead to tooth regeneration one day. A vaccine that fights cavities is in the works. And dentists are analyzing reams of data to figure out the very best practices for their profession.
Dominick DePaola, DDS, president and chief executive of The Forsyth Institute in Boston, sees these innovations profoundly changing dentistry over the next 10 years as the field moves from the drill to biotechnology.
"There is a movement in dentistry from mechanical technologies to a more biological approach," DePaola observes.
Intelligent fillings
Fillings are a basic part of any dentist's toolbox. Yet over time, many fillings need to be replaced because decay attacks them.
Fred Eichmiller, DDS, director of the American Dental Association Health Foundation's Paffenbarger Research Center, says his organization is working to develop fillings that release fluoride when they encounter acid that causes decay.
"We want materials that react to their environment," Eichmiller states. "The challenge is to have materials that release fluoride over the 30-to-40 year life of the filling. You need a large reservoir of fluoride in the material, unless the filling releases fluoride only when it comes in contact with acid."
Smart-filling technology is five to seven years away for mainstream adoption, Eichmiller predicts, but there are already sealants and orthodontic adhesives available in the market that work on similar principals. He doesn't see the cost prohibiting the use of these smart materials.
"The cost difference between a smart filling and a regular filling will be small, plus the smart filling will last longer," Eichmiller notes.
Bone and tooth regeneration
Smart fillings are just the start of what dentists may be able to do with teeth and bone. Eichmiller notes that some dental surgeons are working with materials that help create bone.
A powdery substance used by neurosurgeons in skull reconstruction is gaining acceptance among dental surgeons who apply the material to patients' jaw bones to strengthen them for dental implants.
"Right now, a dentist can only put an implant where there's bone strong enough to support it. That might not always be the best place for the implant. So this powder allows us to be more flexible," Eichmiller says.
New technology also gives dentists the ability to fortify teeth before they're lost to decay. When a tooth starts to decay, minerals are literally sucked out of it, weakening it even more. Dentists have begun to use more chemicals and techniques that "remineralize" teeth that are susceptible to cavities, reversing the decay process, says Erick Rabins, president of Dentigenix Inc.
Rabins' firm is a wholly-owned subsidiary of Ivoclar-Vivadent Inc., one of the world's largest manufacturers of dental products. Dentigenix is working with The Forsyth Institute to help commercialize tooth regeneration techniques. "In the future, we may just implant a tooth bud when someone loses a tooth, but that's a quantum step. There are a lot of interim steps in between," Rabins says.
The first move to tooth regeneration is already here. In 2002, researchers at The Forsyth Institute developed tissue engineering techniques to grow biological mammalian tooth crowns - step that could lead to a tooth substitute grown from an individual's own cells.
Forsyth researchers used enzymes to isolate immature tooth cells from pigs. They implanted the cells on a biodegradable, spongy material called a "scaffolding," then implanted the cells in a rat near its intestines. Within 30 weeks, small tooth crowns had formed.
The research team, led by Pamela Yelick, Ph..D., a member of the Forsyth staff and an instructor in oral and developmental biology at the Harvard School for Dental Medicine, has predicted that the techniques could be ready for clinical testing in 7 to 10 years.
In the meantime, Rabins suggests dental techniques that remineralize teeth on the verge of decay can be an effective way of cavity prevention.
"I see biotechnology gradually impacting dentistry," Rabins observes. "Unlike other medicine, dentistry doesn't have huge research hospitals pushing dentists to innovate more. Dentists mostly operate like independent businessmen."
Cavity shots
Advances in dentistry are going beyond the dentist's office. Forsyth researchers aim to prevent tooth decay throughout life by administering a vaccine to children aged 12 to 24 months.
"The vaccine wouldn't need to be given in a dentist's office. In fact, it might make more sense for a pediatrician to administer it," notes Forsyth researcher Daniel Smith, Ph.D., who is working on the vaccine along with a research team.
Smith and other researchers discovered a potentially important antigen for a vaccine against dental caries, which is a widespread infectious disease that occurs when microorganisms accumulate on the teeth, especially in the presence of sucrose. The microorganisms - mutans streptococci - produce lactic acid, a product of sugar metabolism that causes tooth enamel to erode. The vaccine works by stimulating immunity to an enzyme, which is responsible for the accumulation of the mutans microorganisms on teeth.
The antigen is the key component in a new formulation of a vaccine that can be squirted into the nose, rather than injected or swallowed like some other proposed dental vaccines. This vaccine has proved effective in pre-clinical trials, Smith says. Smith and other researchers have previously received approval to enter clinical trials and are currently seeking partners to produce the vaccine.
Crunching numbersVaccine advances and biological tools present a challenge for dental insurers because a biotech approach to dentistry will focus more on prevention rather than the "drill, fill and bill" method most dentists are familiar with, notes Jeff Album, a spokesman with insurer Delta Dental of California. Dentists traditionally have been paid for procedures instead of prevention.
"It's the $64,000 question in dentistry," says Max Anderson, DDS, vice president and dental director of Delta Dental's Washington Dental Service. "But I think we can find a solution that works because the medical insurance industry is able to reimburse internal medicine specialists for their services, which are preventative in nature."
One way to help insurance companies embrace technological innovation is through evidence-based dentistry, Anderson indicates. By examining research studies, claims data, dental statistics and research initiatives, medical epidemiologists have provided dentistry with a way to measure the effectiveness of different techniques, treatments and procedures.
That's not to say that dentists don't use evidence in their day-to-day practices, Anderson notes, but that many dentists aren't aware of the all of the latest research in the field. Every year, for every dental specialty, some 500 reports on clinical trials are published in more than 50 separate journals. Evidence-based dentistry sifts through the data and can help dentists and dental insurers figure out which innovations are effective, he explains.
Delta Dental helps support a center for evidence-based dentistry at Forsyth.
Dentigenix's Rabins says evidence-based dentistry will lay out the statistical foundation for insurers to support new technologies and methods in dentistry. However, if insurers don't cover a popular new technology, many consumers won't mind shelling out money for it, he predicts. "Unlike medical insurance, most people are used to paying a couple hundred bucks if they have to have work done beyond a basic cleaning," Rabins says. "Plus, most new innovations in dentistry are around prevention, which will save insurance companies and consumers money in the long-run."