A written interview requested and directed by our editor-in-chief, Dr. Damon Adams, with George Freedman, DDS, BSc, internationally acclaimed lecturer and dental materials editor for Dentistry Today.
What do you see as an important consideration for clinicians, related to all the changes occurring in the profession?
Dr. Freedman: Dentistry has been evolving rapidly in recent decades. It can often be a challenge to dental professionals to keep up with all the developments that are occurring simultaneously. It is vital for the practitioner to identify important trends within the profession such that they can maximize their time spent in learning and their money spent on upgrading.
What would you identify as the major trends in clinical dental materials?
Dr. Freedman: Developments in dental materials tend to be evolutionary rather than revolutionary. In order to identify important current and future trends, the easiest technique is to examine recent directions of research and commercialization, and to extrapolate them into the coming years. For example, amalgam restorations, popular for more than a century, have been largely replaced by tooth-colored materials in a span of just 20 years. Dental professionals seeking to improve patient treatment are searching for restoratives that can positively impact upon the health of the remaining tooth structure during extended periods of time. We are seeing the introduction of bioactive restorations that, beyond replacing decayed and missing tissues, interact with tooth surfaces to discourage bacterial activity and to strengthen the restorative interface. These bioactive materials represent the near and intermediate future.
Bonding agents, first introduced in the 1970s, have gone through 7 major formative generations. Each successive adhesive generation was more predictable and less technique sensitive than the previous one. Thirty years ago, the resin practitioner was faced with a veritable chemistry set of materials to mix and match, in very specific sequences, in developing a micromechanical bond between the tooth and restoration. Today, the dental bonding standard is the 7th generation single-component, single-step dental adhesive: strong, easy to place, tooth-friendly, and totally predictable. Where can we go beyond single-step adhesives? Very simple: zero-step adhesives. Incorporating the adhesive component into the restorative material is just around the corner. The technology is already available; it is being used in the one-step resin cements. The next major evolution of dental adhesives, the 8th generation, will see the elimination of this treatment process as a separate step.
Indirect dental restorations must be affixed to the remaining prepared tooth structure. The original luting cements were rather problematic, soluble in oral fluids, irritating to vital tooth structures, unaesthetically opaque white in color, and difficult to mix properly. Since 1990, resin cements have become dental standards. The early ones were difficult and technique-sensitive to mix, and required many separate steps. In recent years, the automix, one-step resin cements have simplified the final indirect restorative phase significantly. While some of these materials are reactive with tooth structures, they do not chemically bond to all restorative materials. In the near future, the incorporation of silanes and other ceramic and metal catalysts into the chemistry of the one-step resin cements will securely adhere indirect restorations to tooth preparations, developing a true monobloc.
What would you identify as the major trends in technology?
Dr. Freedman: We have acquired and adapted relevant equipment from various segments of the medical field in addition to developing new methodologies from within. If we wish to predict the technological direction of dentistry, it is a simple matter to examine proven medical gadgetry, and to imagine its focused application to the oral cavity. Typically, medical innovation precedes its dental counterpart by almost 20 years.
Dental radiology had changed very little since the times of Röntgen. The introduction of digital radiography reduced patient radiation exposure, added the ability to manipulate diagnostic images, and simplified data storage. In less than 25 years, digital radiology has redefined dental diagnostics. As we move confidently and more affordably toward mainstream tomography, the dentist will begin to view both health and disease very differently. The next decade will see the arrival of the 3-D diagnostic standard; the practitioner will have the opportunity to specifically locate disease and examine the generalized health status utilizing 3-D modeling. Rather than a 3-D superimposition on a 2-D film or screen, requiring an educated guess to pinpoint the exact position of the problem, tomography will enable the most conservative and direct treatment possible.
The rise of oral cancer in groups not previously considered to be at risk (younger nonsmokers, nondrinkers, and females) is rather alarming. A rapid visual scan of the oral cavity during routine examination may disclose suspicious tissue changes that have progressed to, or have begun at, the surface. Unfortunately, many precancerous epithelial lesions occur below the tissue surface at the basal membrane. These subsurface oral abnormalities are invisible to the naked eye until they grow through the epithelial layer, at which stage the best opportunities for early discovery and intervention have been lost. The recent combination of high-powered LED lights and innovative filtration utilizes natural fluorescence visualization to identify clinically invisible anomalies. Cancers and precancerous epithelial lesions down to the basal membrane are now identified and mapped for follow-up investigation (biopsy) and treatment. The technique is noninvasive and not unpleasant. As such, it is well accepted by patients and sets the standard for diagnostic techniques of the future.
Caries detection is the cornerstone of the dental practice. The earlier decay is identified, the earlier and more conservatively it can be treated. The traditional methods for examining tooth surfaces and confirming dental caries are neither effective nor beneficial to the patient. While the overhead operatory light illuminates dentition well, the practitioner has 2 basic options: if the surface is white, it is healthy; if the surface is dark, it is decayed. There is no allowance made for caries that have been arrested and for discolored, but healthy, tooth surfaces. In the early modes of caries detection, the explorer was jabbed into suspected caries to determine the hardness of the tooth surface and/or the extent of the decay. Not only was this very uncomfortable for the patient, often eliciting howls of protest, but it was also iatrogenic, serving to spread disease very effectively from one tooth to the others. The introduction of fluorescence detectors has vastly changed the parameters of caries screening. Today, totally noninvasive techniques visualize the tooth surface in the detection mode (to locate problematic areas) and in the analysis mode (to pinpoint the severity of the lesion and the need for treatment in distinct colors). This diagnostic modality helps the dentist focus on areas requiring treatment and quantifies the disease status. Tooth-restorative interfaces are typically very difficult to evaluate for breakdown, as amalgam and composite can confuse visual interpretation. Fluorescence caries detection eliminates the doubt. In the near future, the blending of innovative caries detectors and small field tomography will yield diagnostic capacities that are unimaginable today.
Dental lasers have completely re-vamped minor surgery in the dental practice. The benefits of this technology were evident many years ago, but the lasers themselves were cumbersome, difficult to use, and far too expensive. The diode revolution transformed the playing field; floor models became countertops, complex protocols were simplified to presets, and prices tumbled from a mini-mortgage to that of a handpiece. Laser utilization mainstreamed from hundreds to tens of thousands of dentists. The advantages of laser procedures extend into every branch of dentistry—orthodontics to prosthodontics to endodontics. And the proactive impact of these minimally invasive technologies is just beginning to be felt in preventive dentistry. We have already seen lasers used to treat hard tissues such as enamel, dentin and bone; these directions are likely to expand to an era where much of the surgical energy that is used for oral treatment will be light beam rather than rotational. Light mediated therapy can be more focused, is less harmful to the immediately adjacent tissues, and offers a more rapid and improved healing. It can be readily predicted that the combination of tomographic diagnostics will be used to guide precise laser intervention, perhaps by dentist-positioned robotic units, in the treatment of dental disease.
Photo-activated technologies may be in their infancy, but research is pointing to great benefits for both patients and dentists. Typically, these techniques are highly proactive and minimally invasive to tissues, both hard and soft. The general concept is that various wavelengths of light can stimulate desired responses in natural tissues, or alternatively, targeted tissues can be seeded with specific receptors that in turn are activated by a light beam. Specific wavelengths can be focused at the tissue surface (or below the surface) to encourage healing by stimulating beneficial responses and leading to the resolution of inflammation. Future enhancements in delivery modes and targeting technologies will further refine this highly desirable treatment approach.
Dental impressions, as recently as my time in dental school, involved offensive-smelling rubber base, inaccurate alginate, and a whole host of memorably unpleasant techniques. The great progression to polyvinyls, polyethers, enhanced polyvinyls, and precise alginate derivatives have all made dental impressions pleasant for the patient and predictable the practitioner. During the past decade, dentists have begun to scan prepared teeth optically rather than impressing them physically, and today this is a widespread modality. Initially very expensive, these technologies are now firmly within financial reach. Their accuracy and ease of use are improving as we watch. The predictable trend is that optical impressions (readily obtained and transmitted to the laboratory online) will en-tirely replace traditional impressions in the near future.
What would you identify as the major trends in dental education delivery and formatting; how are the new education technologies and dentist preferences altering access and consumption of information?
Dr. Freedman: Education is always changing. It is highly responsive to the needs of those interested in acquiring new information and their current learning preferences. It is also highly dependent upon the techniques and the settings of those in a position to provide this new information, and their current preferences. Continuous learning is, or should be, the basis of every practitioner’s professional commitment to dentistry. Typically, at any given time, approximately 30% of dentists are actively seeking to advance their knowledge; they read magazines and books, they attend conferences and lectures, and they participate in hands-on and extended programs. They, in turn, are in a position to offer their patients the best and most current treatment options. Unfortunately, the 30% tends to be the same group of dentists throughout time (you see the same faces at meetings over and over). Fortunately, licensing laws and regulations require all practitioners to be relatively up-to-date with knowledge, targeting the remaining 70% who are less proactive in their educational activities.
Educational patterns are changing for a variety of reasons. In the recent past, education was the exclusive domain of academic teaching institutions and dental conferences. During the past 2 decades, dedicated organizations, such as the American Academy of Cosmetic Dentistry and the American Society for Dental Aesthetics, have focused on leading-edge topics and techniques far more quickly than was possible within traditional academic institutions. This information was generally not available elsewhere. This attracted individuals who were interested in providing specific treatment modalities to their patients. The rise of specialty and quasi-specialty meetings in cosmetics, orthodontics, implants, sleep apnea, etc, has been a testament to dentists seeking to expand their horizons. The larger meetings are likely to continue to decline slowly until they reinvent their message to the practitioner, as they tend to do every 10 to 20 years. The smaller, more focused, more information-aggressive meetings are likely to maintain their attendance within their special interest groups.
Other factors, nondental in origin, are also having an impact on dental education. Travel to meetings is more difficult, more time consuming, and more costly. Taking extensive time away from the practice is cost prohibitive as well. In addition, many of the presentation offerings are of marginal interest to the clinical dentist, and may be repetitive of knowledge already acquired. Dental manufacturers and distributors, long the bankrollers of dental education, are also having a more difficult time participating in (and paying for) the vast proliferation of dental meetings in every state, every county, and every city.
The rise of Web-based education has again changed playing field. First, the quality of online programming, not subject to peer review and evaluation, is very uneven. Excellent programs are found side by side with time wasters, and there is little, if any, standardization. The other concern with online education is that the provider may have specific “selling points” and marketing objectives; this should not be a problem as long as the relationship is clearly identified, which all too often is not. The cost of taking these programs ranges from ridiculously expensive to totally free. The true value for the practitioner is virtually impossible to pinpoint.
Thus, the online education arena is a potential minefield for the unsuspecting dentist. Fortunately, there is a system of organization, definition, and evaluation that has come to online programming. For the first time, university-based certificate, diploma, and master’s programs are being offered online. These are comprehensive, long-range programs that compare favorably with the attributes of their live-attendance counterparts, and more. Typically, their faculty members are leaders in their fields, offering the latest materials and techniques. There are more—and more relevant—lecture sessions. The literature reviews and searches are more focused and detailed, and are examined on a regular basis. Treatment planning exercises have been transformed successfully to online platforms. In many disciplines, clinical cases are required from the participants, some in step-by-step detail. Most important to the clinical dentist, all of the education is available online at convenient times. Practitioners do not have to give up their practices for 2 to 3 years (for a master’s program) or valuable chair time to attend daytime courses. Almost all of the educational processes can be completed at the discretion of the attendees, at their convenience, in the comfort of their practices or homes. Up until now, the only missing link in online education was the personal exchange between teachers and students; today, the availability of online e-tutorials and virtual over-the-shoulder (VOTS) interactive teaching has filled the gap. High quality simulators that are affordable for individuals enable private hands-on education for practitioners within their own office. Since physical location and equipment requirements are lessened, the costs of these university-based certificate, diploma, and master’s programs are more favorable and easier for the dentist to cover while in full-time practice. Overall, online education is easier and more convenient, but the dentist must select the right program.
The impersonal, large classroom format of dental education is largely passé. Dentists are demanding meaningful personal contact with their educators to make learning time more relevant to their own practices. The value of engaging the instructor in a one-on-one discussion cannot be overstated. Thus, smaller, more focused educational events are becoming increasingly popular with the profession. Participants engage with a single instructor for the entire day (or a part thereof). As they become more familiar with the delivery format and the thought processes of the teacher, the process of information transfer to the dentist in the small audience increases in effectiveness. When there is an opportunity to immediately try the materials and technologies discussed in a hands-on setting, the learning experience is further enhanced.
At one time, dental lecturers could get away with presenting beautiful pictures of birds, flowers, sunsets, and their cars for a significant part of their allotted time. Now, as dentists have more choice in sourcing their education, they demand that teaching be focused, specific, up-to-date, and relevant to their clinical practice. “More stuff and less fluff” accurately describes the successful presentation.
What would you identify as the major trends in the evolution of patient treatment options, and which ones are they most excited about?
Dr. Freedman: The major directions for patient treatment all involve 3 underlying concepts: proactive (diagnosing and treating problems early or before they start), minimal (treating problems as conservatively as possible), and comfortable (ensuring that the patient/consumer has a pleasant overall experience). These concepts apply to the traditional pursuits of the dental practice such as direct and indirect restorations, endodontics, orthodontics, implants, etc. Dentists who do not offer (or promote) these parameters to their patients will find themselves far less busy than they would like to be.
There are novel areas where clinicians can take responsibility if they choose to do so: treatment of temporomandibular disorders, sleep apnea, bad breath, perioral dermal treatment, smoking cessation, and nutritional counseling, among many others. Each of these treatment area extensions can have a major positive impact on the dental practice; just think of all the benefits that tooth whitening has brought to the profession.
One real cause for concern is the pressure on the dental profession, and the surprising willingness of certain dental representative bodies, to allow devolution of dental services and responsibilities to groups that are not properly trained for these tasks. The pressure on the politicians who enact these rules is financial and electoral; they see dentists as a rich and powerful group that is easy to bring to their knees. (In fact, most dentists are small businesspeople who are making a comfortable living, but are not getting rich. The current costs for a dental education are so high that many young practitioners will spend a significant part of their working lives paying off their academic expenses.) Organized dentistry and its elected leadership must serve to protect the public and the members of the profession by opposing and preventing the devolution of all unsupervised services to the less trained and less capable.
Patients get more excited about certain treatment options than others. Tooth whitening and porcelain veneers (cosmetic dentistry) have been extremely popular and have propelled the recognition and acceptance of the dental treatment more than all other factors combined. The use of dental appliances for sports, as well as for more comfortable sleep, has increased public awareness and familiarity with dental treatments.
The role of implant dentistry has been established for more than 2 decades. Yet this modality is just beginning to hit its upward curve. The major barrier to the extensive use of implant techniques to restore missing teeth and lost function has been the cost! The technical and clinical problems were solved long ago. The unrealistically high expense of implant hardware, combined with the early, uncompetitive positioning of the surgical, restorative, and laboratory fees, served to limit patient acceptance and utilization. Now, as implant hardware costs have plummeted, and dentists and technicians competitively seek to find reasonable remuneration levels for implant-associated procedures, patients are benefiting, and increasing numbers are choosing this excellent treatment modality. Once the market has derived appropriate treatment fees, implants are going to be the norm rather than the exception in the replacement of missing teeth.
One has to wonder what the treatment choice ramifications will be for a patient with a badly broken down tooth in the near future; when the costs of an endodontic treatment plus post-and-core plus crown are equivalent to an extraction plus implant plus crown, which will be the more conservative and longer-lasting option? And which will be more popular as a patient selection?
The most dramatic trends in pa-tient treatment options will occur as a result of combining existing and new technologies that make dental practice better, faster, and easier. We have seen this with the increasing utilization of implants for denture stabilization. Currently, the use of 3-D tomography to accurately plan implant placement facilitates placement. Comprehensive jaw movement analysis precisely records the state and the mobility of the mandible joint to optimally design prosthetic treatments in a fully functional and comfortable position. Adding sensors and actuators to dental sleep appliances will improve the patient’s nocturnal rest and waking hours. The age of synthesis, putting independent scientific and clinical knowledge together, is upon the dental profession.
What are the trends in the evolution of the dentist-patient interaction?
Dr. Freedman: Ultimately, practice success has always depended on the interaction between the dentist and the patient (and the staff, of course). This is unlikely to change in the near or the far future. However, the dentist-patient relationship has been changing for many years, and is likely to evolve more rapidly in the near future. The patient today is broadly informed, but not always well informed. The information readily available on the Internet is rarely vetted for accuracy or fact. In fact, misinformation is much more likely than real understanding. Patients, however, assume that they are knowledgeable and will often confront the dentist with their knowledge. It is essential for the practitioner to correct the patient’s misinformation without offending or belittling the patient. This is sometimes a difficult task. It is far better and easier to have an effective educational program available for patients in the reception area, in the treatment rooms, and while waiting for procedures. This proactive transfer of information may offset some of the incorrect data that has been gathered by the patient, and may lead to questions that will ultimately encourage appropriate treatment.
Increasingly, the dental team is focusing the patient’s home care by recommending specific maintenance procedures. Patients who do not re-spond to flossing may be more amenable to water flossing. Individuals with halitosis and/or long-term periodontal disease due to poor oral hygiene may accept medicated rinses on a regular basis. Those with excessively dry mouths are actively seeking oral moisturizers. More and more home-applied therapies are available on the recommendation of the dental team, and the successful practitioner will use every possible device to improve patients’ oral health in the long periods between recare appointments.
What trends can we expect to see as the new clinical standards in the next 12 months, and in the next 5 years?
Dr. Freedman: In the next 12 months, we are likely to see a major restructuring of the dental implant segment, the costs to the dentist and pa-tient, and a significant increase in their popularity and utilization. The percentage of dentists sending optical impressions directly to the laboratory will grow. Bioactive restorative materials will be the latest and greatest in restorative dentistry. More restorative materials will be self-adhesive, heralding the advent of the 8th generation, or no separate adhesive at all. The relationship between oral health and systemic health will become more firmly established in the public’s mind, en-couraging better oral care and more dental consultation.
During the next 5 years, even greater changes are expected. The diagnostic and surgical technologies required for implant placement will make the process so predictable that most general practitioners will choose to embrace the procedure rather than send it out to specialists. Dentists will not only take impressions optically, but will utilize 3-D modeling and printing to create the required shade-matched crowns and bridges within minutes right in the practice. Remineralizing and regenerative restorative materials will build nature-mimicking structures that closely resemble natural teeth. The dental practitioner will be in a unique position to assist in diagnosing and treating systemic diseases.
The past hundred years have demonstrated a rapid growth in dental technology and an even more rapid development of dental materials. The past 2 decades have offered quantum leaps in the restoration of oral health, function, and aesthetics. By simple extrapolation, the future is golden for the dental profession. It is an exciting time to be a dentist!
Dr. Adams: George, I want to thank you for your time taken to prepare these thoughtful and forward-looking insights on some of the latest and important trends in the profession. Our readers will surely benefit from the depth of candid information that you have shared. See you on the road!
Dr. Freedman is a founder and past president of the American Academy of Cosmetic Dentistry, a co-founder of the Canadian Academy for Esthetic Dentistry, and a Diplomate of the American Board of Aesthetic Dentistry. He is a visiting professor at the Universita di Firenze, Florence, Italy, and he is the materials editor for Dentistry Today. He is the author or co-author of 13 textbooks, including his most recent textbook, Contemporary Esthetic Dentistry (Elsevier), more than 700 dental articles, and numerous webinars and CDs, and he is a team member of REALITY. He lectures internationally on dental aesthetics, adhesion, desensitization, composites, impression materials, and porcelain veneers. A graduate of McGill University in Montreal, he maintains a private practice limited to aesthetic dentistry in Toronto. He can be reached at (905) 513-9191 or email@example.com.