In honour of Dental Update's golden anniversary, this article reflects on current innovations, and takes a look at where the profession is heading in terms of development and technology that promises to add to patient care and quality of outcome.
Values and habits
In the UK, there is a fragile balance between the state-funded system and the private sector in the provision of dental services. The complications of limited funding, population density changes, and increases in dental health awareness and prevention have led to a relative shortage of services within the NHS. This, along with events such as the pandemic, has given rise to the relative increase in private sector uptake. People have a better awareness of their dental health and place a greater value on it. It is clear to see that changes in awareness and prevention have changed hugely over the past two or three decades.
The prevalence of conditions such as oral cancer has risen due to a host of factors. Data show that the number of cases of oral cavity and oropharyngeal cancer doubled between 2000 and 2016,1 while the incidence of adult head and neck cancer in the UK increased by 34% between 1993–1995 and 2016–2018.2 These increases have led to major advances in the promotion of healthy lifestyles and awareness, and so this alone represents one of the major changes over the past 50 years in terms of cultural awareness in relation to dental health.
Cultural shifts have also taken place with regard to the management of restorative strategies employed within the profession. Minimal intervention and prevention has superseded more interventional approaches. The scope of restorative dentistry has also expanded and it is no longer just a functional healthbased provision, but increasingly has an aesthetic dimension. This has again heightened awareness of dental health, and has also opened up a new market for dental services. The use of heavy metals contained in traditional amalgam compounds has been consigned to the past, and more elective treatment to improve appearance using orthodontic, direct and indirect methods is taking us into the future.
Business
Dentistry has become an asset in the eyes of the corporate bodies, as well as individuals, who wish to own multiple sites. This is on the increase within the UK and North America, with varying levels of benefit and success. The relinquishment of practices has become attractive for many practice owners, not only as they come to the end of their practising career or have a change in direction, but also as a result of the added responsibility of adhering to new rules and regulations that have changed the face of practice ownership. Greater levels of clinical and non-clinical governance have placed extra responsibilities on the principal and the team to the extent that there is a now a place for businesses that focus solely on this level of management within dentistry.
Dentistry and charity
The benevolent aspect of dentistry has emerged over the past 20–30 years to a greater level within the UK and internationally, spanning corporate social responsibility and the support of local groups and charities, through to international aid and provision of dental services in rural parts of Africa. Various groups have also emerged that look after the welfare of colleagues within the profession who are experiencing tough times. Dentistry has always been a highpressure occupation, and it is clear that the need for greater professional support has grown in the past few decades.
Clinical innovations: training and continuing development
The span of dental education has hugely increased over the past decades. There are now more opportunities than ever to develop and adopt new skills to improve clinical ability, widen the span of provision, improve confidence and specialize. This has invariably had an impact on skillset and remit of services provided within the UK, which is now more controlled than ever by our regulatory body. Dental Update has, of course, been there throughout the whole period!
Clinical technology
The digital era
The past few decades have seen the development of digital technology. The use of technology, such digital cameras, intra-oral scanners, CAD/CAM in-house milling, digital design, CT planning and 3D printing, has revolutionized the practice of dentistry. This digital movement has opened a realm of provision that benefits the patient in terms of comfort, workflow and, in most cases, results. The investment into this industry has been substantial, and it shows no signs of slowing. This has placed some pressure on clinicians to also adopt new skills and workflows, as well as acquiring/investing in training and hardware. This has enabled the profession to become more sustainable by reducing paper records, dental plaster and die stone consumption, with a greater reliance on automation.
Computers and artificial intelligence
The role of artificial intelligence (AI) is relatively new within dentistry. It has also allowed patients to become more informed than ever. Within the dental team, record keeping, radiography reporting, orthodontic movement tracking, smile design software and even use of nanotechnology has become reality.
Materials
One of the most dynamic aspects of current dentistry is the range of materials that is available. Many different ceramics now exist and composite materials no longer need to be mixed together by hand! In reality, the materials we have now for all aspects of clinical dentistry is vast and ever-growing.
Clinical innovation
So many clinical innovations have become influential in the past 50 years – none more so than osseo-integrated tooth replacement. The dental implant industry is huge, and more implants are placed every year, bringing greater levels of research and access for the public. The implant industry has also extended beyond the dental tissues and also caters for extramaxillary sites such as nasalis, pterygoid and zygomatic implants. Such solutions can also be digitally guided using CT scanning technology and promises to further expand with the use of AI, self-guided placements and greater range of hard and soft tissue substitutes.
The irony of modern modes of tooth replacement, such as osseo-integrated implants, is that this allows the profession to learn more about natural physiological mechanisms of eruption, integration and intra-oral tooth formation – all of which are currently being researched and are likely to reach the shores of the progressive general dentist in the form of tooth regeneration techniques. In the meantime, technological advances allow us to go full circle and realize that sometimes the answers are right in front of us. Figures 1–7 illustrate the procedure of autotransplantation, where an intact tooth is transplanted from one area in the mouth to another. It is a procedure that is growing in evidence, longevity and success. Such a case is illustrated where premolar teeth were transplanted to the aesthetic zone and then built up using direct composite, which can be finished and polished to such a level that long-term, realistic and stable outcomes are commonplace.
These types of procedures have been deduced from a greater understanding of the attachment and bone complex that arguably, without research into osseo-integrated implants, we may not have considered that such factors can lead to predictable outcomes. Such techniques have been documented for some years. In 2009, Amos et al presented an overview of this technique, and highlighted the possible risks of resorption being outweighed at that time by the advantages of this technique.3 Sufficient evidence exists to suggest that subject to appropriate case selection, pulpal health can be maintained in immature apices where the diameter is greater than 1 mm in 87% of those undergoing the procedure.4 Alternatives to such treatments include osseo-integrated implants. The issue, however, is that the ankylosing nature of osseo-integration results in infraocclusion of the tooth in relation to the developing dentition.5 Consequently, the natural interface, combined with advances in restorative materials, may provide the key, possibly in conjunction with nanotechnology, to providing long-term predictable outcomes.
Nanotechnology has already played a role in advances in regeneration of hard and soft tissues,6 such as regeneration of cartilage in the temporomandibular joints, pulp repair and periodontal ligament regeneration.7 Such advances have the potential the disrupt our current workflows and techniques. However, further research and subsequent commercial availability will take some time, and it will be years before this technology becomes mainstream.
Conclusion
Dentistry means more to more people compared with 50 years ago. Is this too bold a statement to make? It may be said that the public are beginning to sit up and listen to messages from the profession on health promotion, oral cancer and prevention. When 50 years is reviewed in terms of certain industries, traditional methodologies are often celebrated, such as authentic recipes and food preparation. Dentistry, however, is not the same as vintage Parmigiano Reggiano! When it comes to dentistry, we are in an exciting time where constant disruption of our workflows, as well as good, consistent research leading to predictable outcomes for the coalface of our profession centres our decision-making when providing optimal care for our patients.
In terms of what can we do as primary and secondary care providers, Atul Gawande, in his book The Checklist Manifesto8 describes our workflows as, at times, being determined by dogma and tradition, which, when broken down, reassessed and truly evaluated can result in better efficiency, efficacy and outcome. This checklist does not have to simply be technological. Reflection on keeping things simple, delegation, training and determination have been shown to be very relevant for the forward and progressive mindset that we need to consider in our positions of responsibility.
In another 50 years, the advances may be beyond our wildest dreams if this current rate of progression continues…the future remains bright, so watch this space.
Coming full circle: case presentationThis case, conducted by Dr Naomi Doelen, illustrates life-changing techniques using autotransplantation into the aesthetic zone, thus negating the need for technological advancements, such as osseo-integrated implants.
Figure 1. The patient was 9 years old with a fractured UR1 with resorption, and an avulsed UL2 (extra-oral time was 3 hours).
Figure 2. OPG showing root resorption and avulsion.
Figure 3. (a,b) Unerupted upper 2nd premolars were autotransplanted with no augmentation. The follicles were left intact around the teeth.
Figure 4. Radiographs taken (a) immediately; (b) 3 weeks; (c) 6 weeks post-operatively; and (d) after reshaping.
Figure 5. (a,b) At 6 weeks post-operatively. Note that there was no splinting, excellent soft tissue healing, and maintained out of occlusion.
Figure 6. (a) Before and (b–d) after composite resin shell placement.
Figure 7. (a–c) Restorations completed and ready for orthodontics.
