The Future

21st Century Dentistry

By Douglas K. Curley

Imagine a world without dental decay and a United States where there are fewer than 53 dentists per 100,000 people. The dental office in that world would likely be paperless, and nearly computerless.

Fifty years ago such statements would be described as 21st century fantasies. Today is the 21st century. Those prognostications are realities for the most part, or widely accepted projections.

Professionals practicing in this strange new world will have a changing face. According to Arthur A. Dugoni, DDS, MSD, dean of the University of the Pacific School of Dentistry, they will likely be younger, more ethnically diverse, and more specialized. Based on graduation and retirement projections, along with population growth, there will also be a greater patient pool per practitioner.

At the University of California at Los Angeles School of Dentistry, a group of researchers are pursuing what in medicine would be analogous to curing the common cold. They want to eliminate tooth decay altogether. If successful, David Noel, DDS, MPH, chief dental consultant for the California Department of Health Services, says, the Denti-Cal program can change its emphasis from treatment to absolute prevention.

While the move toward a paperless society is slowly encroaching into the professions of medicine and dentistry, Eugene Sekiguchi, DDS, 13th District trustee to the American Dental Association and a member of the ADA’s Standards Committee on Dental Informatics, says more dramatic technical changes are in store for the office of the not-too-distant future. Instead of computers, he says, practitioners may be hooked up to national information services. In essence, dentistry may go dot com.

Ready or not, the 21st century has arrived.

A Shrinking, Specialized Workforce

"The 21st century is going to be a wonderful time to practice dentistry," Dugoni says. "New technology and science, coupled with a decreased output of dental grads, could make for a golden age of dentistry. But it won’t be without new challenges."

The combination of population growth and dental school closures is beginning to have a dramatic effect on the ratio of dentists per population. According to studies reported by both the American Association of Dental Schools and the ADA Bureau of Economic and Behavioral Research, the number of practicing dentists in the United States will peak this year and then level off before beginning a gradual decline. Because the U.S. population continues to grow, the ratio of dentists to the general population will drop earlier and more sharply, falling by the year 2020 to an estimated level of less than 53:100,000 (Table 1).




According to Dugoni, the projections in the dentist workforce reflect the combined effect of the retirements of dentists trained during peak enrollment years (Table 2) and the reduced enrollments of more recent years.

"Six or seven dental schools have closed over the past decade or so," Dugoni says. "Overall dental school enrollment has decreased by about 35 percent since the ’60s. At that time, we were graduating about 6,300 students per year. Now we’re at just over 4,000 annually."

The cuts in dental school enrollments have primarily affected the supply of general dentists, which is of some concern to Dugoni.

"Dentistry has always taken pride in that, unlike medicine, we are 80 percent generalists and 20 percent specialists. But that will likely change to 25 percent specialists in the very near future," Dugoni says.

Just do the math. According to Dugoni, 1,200 specialists are graduating each year, while the number of generalists graduating is holding firm at 4,000. The number of specialty training positions has not increased, but the ratio of such positions to dental school graduates has increased. Thus, according to AADS projections, the proportion of dentists who are specialists is projected to increase to more than 25 percent by 2020.

"It’s almost funny how the dental workforce situation has gone full circle in about 20 years," Dugoni says. "I can remember back in the early ’80s when the cover of a Forbes magazine announced ‘Dentistry Is Obsolete’ -- that due to the oversupply, the profession was going down the tubes. Now, if anything, we have a shortage in the applicant pool."

That pool also has a changing face.

Since the early 1990s, the number of women graduating from dental schools has increased dramatically. However, according to Dugoni, this growth has recently flattened. It’s now holding steady, nationwide, at about 40 percent. He says the profession has made impressive strides in ethnic diversity in the past 20 years, but he admits that there is still more work to be done.

"In California, we have had great success in continually attracting more and more Asian applicants to our dental schools," Dugoni says. "But we still haven’t sufficiently addressed the Hispanic and African American population. Based on the state’s demographic makeup, we still have a long way to go."

The practicing dentist of the 21st century will demand much easier mobility, according to the former ADA president.

"Today’s family is typically a two-professional family. There may be an attorney and a dentist. If one spouse gets a job out of state, the other follows," Dugoni says. "That’s only going to become more common in the years ahead."

He says organized dentistry has taken major strides in the past 10 years in addressing this freedom of movement issue. The establishment of four regional boards has made it much easier for a credentialed dentist to move from region to region. But he says there’s still much work to be done, particularly in California.

"It’s been a long time coming, but California is slowly accepting the idea of licensure by credential. CDA membership has voted by 80 percent in favor of the association considering other options for licensure," Dugoni says. "In the next few years, we need to embrace the idea of a core examination, with calibrated exams. We have to get to the point where regions are talking to one another. If we want the best applicant pool, we’ll have to become even more flexible in terms of freedom of movement in the years ahead."

One downside to the roaring economy the nation and the profession has been enjoying in the past several years is the widening difference between the salary of a practicing professional and a dental educator.

"The economy is so strong that dental educators’ salaries are now trailing that of practicing professionals, especially specialists, by as much as two or three times," Dugoni explains. "Just last year, I lost four specialty instructors to group practices. Each of them left for jobs that will pay them four times what UOP could pay them."

California is not alone. According to Dugoni, there are currently 300 unfilled positions at dental schools nationwide.

"There’s no easy answer to this disparity. Dental schools are not alone in this problem. Society is underpaying educators from the K-12 level all the way up," he says. "Hopefully we’ll find a solution to this problem in the new millennium."

Curing Dentistry’s Common Cold

"Imagine a world without tooth decay," Noel says. "Imagine the money the state of California could save on Denti-Cal if instead of spending money on fixing teeth every two years, we invest in ensuring every mouth is free of decay-causing bacteria."

Bacteria are the key, and Noel has become the state’s biggest supporter of studies in this area. Research is currently underway on developing methods for both diagnosing the presence of and treating the seven bacteria identified as causing tooth decay.

"Tooth decay is caused by bacteria. There are 500 or so different kinds of bacteria in your mouth; only seven types of bacteria are associated with tooth decay," Noel says.

According to Noel, research shows that nobody is born with bacteria that cause tooth decay. In order to get tooth decay; a person must be infected with the bacteria that cause this disease. Without these bacteria, a person cannot get tooth decay.

"If you have tooth decay bacteria, you caught them from your mother, father, family member, or others who are transmitting this disease," he says.

According to Noel, these bacteria are transmitted in similar ways to those that cause colds and the flu. The infection of tooth decay is also influenced by lifestyle, tooth structure, and mouth chemistry.

"If you accept that tooth decay is a result of a transmitted infection, then the obvious question arises: How do we get rid of the infection?" Noel says.

Other infections are treated through antibiotics, anti-bacterial agents, hygiene, and quarantine. But in dentistry, notes Noel, the treatment for the past century has been partial or complete amputation of the infected tooth.

The current treatment, according to Noel, calls for the introduction of what he calls "bacteria-busting" agents. These agents currently take the form of saliva tests, atraumatic restorative treatment, sealants, fluoride varnishes, chlorhexidine and varnishes, fluoride toothpastes, toothbrushes and floss, diet control, xylitol/sugarless gums, fillings, antacids, synthetic salivas, and fluoridated water.

"This process of attacking the decay-causing bacteria needs to be simplified if we’re ever to succeed in eliminating the infection," Noel says. "The first step we should take is to do whatever we can to prevent people from getting infected with tooth decay bacteria. Secondly, if a person is diagnosed with the infection, we must remove or control the bacteria -- not the tooth. We must halt the decay process in its tracks."

Research is currently under way to simplify this "bacteria-busting" process. Among those carrying out this research are Rory Hume, DDS, the executive vice chairman and former dean of the UCLA School of Dentistry and Wenyuan Shi, PhD, an assistant professor at UCLA. Their research has centered on the development of a monoclonal antibody that selectively eliminates the seven bacteria that cause tooth decay.

"The body naturally creates antibodies," Shi explains. "What we hope to do is introduce a monoclonal antibody to the body that is immune to the cavity bacteria."

Shi and Hume are working to develop this antibody by fusing an immune cell with a cancer cell. The cancer cell has the ability to grow uncontrollably while the immune cell produces the antibody.

"Our research has already achieved its diagnostic purpose, which is the development of a method by which the bacteria of high risk patients are identified," Shi says. "This test works much like that of the common at-home pregnancy test. The saliva-test dipstick will turn one color if the bacteria are present and another if they are not."

Research is still under way for developing therapeutic methods for treating and eventually eliminating the causes of dental caries.

"Once we have the ability to identify high-risk people, the next step will be targeted preventative treatment through modern monoclonal biology treatment," Shi says.

Noel can’t wait.

"This advancement really could eliminate tooth decay. A public health campaign -- similar to anti-drug, tobacco and alcohol programs -- will inform expectant mothers that they and their family members may infect their newborn baby with tooth decay," Noel continues. "Expectant mothers and family will be encouraged to get saliva tests, appropriate oral hygiene counseling, and treatment to remove or control the decay-causing bacteria from their mouths."

By addressing the infection at the cause, Noel says, tooth decay will be prevented in newborn infants. A second change in treatment will be the procedure of removing or controlling the tooth decay infection that exists in a person’s mouth before repairing the damaged teeth.

"Imagine a world where saliva tests are available over the counter. A person can then call his or her dentist with the results," Noel says. "Treatment can then quickly be diagnosed. It may be as easy as calling in a prescription."

And imagine a state of California that doesn’t have to spend $702 million annually in the Denti-Cal program for fixing teeth due to decay.

"We really could spend our time and resources on preventative and esthetic improvement measures," Noel says.

Plug and Play

The idea of a paperless office, although technically not legal yet, is becoming more and more obvious to medicine and dentistry. However, Sekiguchi says that’s just the tip of the technology iceberg.

"Medicine and dentistry are quickly moving toward an all-electronic office," Sekiguchi says. "There’s both good things and fearful things that go along with this technology."

The establishment of standards for software is of utmost concern to ADA.

"He who controls the data wins," Sekiguchi says. "The ADA is working closely with industry leaders in establishing standards, so the practicing dentist can simply plug in and play. We don’t want to see several different types of software for electronic transmission of records and insurance billings. If that happens, we won’t be able to talk to each other."

There is also concern about who controls the information and where it will be stored.

"Ten years ago we fought the establishment of a data bank, fearing that it could unfairly be used against a dentist," the ADA trustee says. "Well, once records begin to be stored, transmitted, and reviewed electronically, there will be a de facto national databank that anybody may be able to tap into."

Finally, Sekiguchi says, the advent of electronic information services for the dental office is not far off. These services will provide the means to transmit billing information and communication with insurance companies. The latter worries Sekiguchi and the ADA’s Standards Committee on Dental Informatics.

"What if these insurance service software programs begin to review diagnosis? This could make the worst HMO look flexible," Sekiguchi says. "You punch in the diagnosis, and the computer program, programmed by the insurance company, spits out the treatment. That’s a little scary."

To ensure organized dentistry’s best interests are at the forefront, Sekiguchi says, ADA is working very closely with the International Standards Organization.

"All we can do is keep providing input and continually stress the need for confidentiality when it comes to patient records," he says.

Nobody said the future would be easy, just exciting.

Author

Douglas K. Curley is a freelance writer and owns Curley.com, a communications firm in Sacramento, Calif.