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Dentistry in 2040, Part Two

In the last issue of the WSDA News, we spoke with key influencers about dentistry in the year 2040, covering topics including insurance, silver diamine fluoride, debt, and integration of medical and dental services. In this issue we continue the conversation, tackling dental school curriculum, changes in the licensure process, and plaque biofilm research. 

The WSDA News sat down with Dr. Sara C. Gordon, professor of oral medicine, Associate Dean for Academic Affairs at the University of Washington School of Dentistry, Dr. Jeffrey S. McLean, a professor and researcher at the UWSoD who teaches first-year dental students microbiology and immunology, and Dr. Bryan C. Edgar, Immediate Past President of the Washington State Dental Association, to get their take on what the future might hold for dentists. 

Dr. Sara C. Gordon, professor of oral medicine, Associate Dean for Academic Affairs at the UWSoD

Curriculum changes
Dr. Sara C. Gordon is well versed in the curriculum changes at the UWSoD, having been brought on to serve in a newly created position to oversee administration of the School’s academic programs, as well as curriculum development, student progress, academic regulations, educational technologies, regional academic operations, and the continuing dental education steering committee. Gordon, who joined the UW nearly three years ago, helped shepherd the recently graduated the class of 2017, which got the third and fourth years of the new curriculum. Clearly, the new curriculum is working. UWSoD students taking the national boards part two scored two standard deviations above the mean. In the past, they had hovered around the mean. “They really knocked it out of the ballpark. We’re proud of them for that,” says Gordon. For their part, students are excited about how much they’re learning in the new curriculum. And while there have been some challenges (particularly as it relates to the labor intensity of the program), Gordon is pleased with the progress and acceptance of the new system. “I like the ways things are evolving here. I came to Seattle, and the UW specifically, because of the vision that the UW had for the new curriculum,” she says. “When I was looking for a new dental school home, my top priority was finding one whose vision matched my own, and that was tough. The UW was doing exactly what I was looking for.”

Dual approach to teaching
The future, according to Gordon, will include a blend of teaching both technique-oriented dentistry and the newer internist approach. She explains, “There is a dichotomy of vision happening in dentistry, much the same as happened in medicine, where you have surgeons and internists. They coexist. I think the same kind of dichotomy is emerging in dentistry, not surprisingly, where you have the technique-oriented dentists and those who are more diagnosis and medically oriented. The UW has strengths in both fields. We have an outstanding restorative dentistry department, and always will, and we’re trying to bolster our students’ internist approach. There are some clear indicators that show this will be important to dentistry in the future.” Those, she says, include patients demanding a patient-centered approach that views them as a whole and not just a collection of body parts and teeth. Secondly, while prevention has always been cheaper and more desirable than treatment, options have been limited. Now those options are expanding every year. “I loved what I was reading in your first article with Jeremy Horst about silver diamine fluoride,” Gordon says, “and there will be more treatments like that in years to come. It’s not a surgical approach, it’s a medical approach at its heart.” 

Gordon acknowledges that teaching integration of medicine and dentistry is vital if students are going to be prepared for technological advances. She says, “We’re training our students in that manner right now, because with the advent of immunotherapy and genetic information, if we don’t they’ll be dead in the water. They have to be able to think about these things in order to be able to use them as tools as clinicians in 10 or 20 years.” Integration training will likely focus on the interwoven nature of the health of all body systems, she says. “You can’t separate the health of the oral cavity, or the stomach, or the brain, or any part of the body from the health of the other parts of the body. This understanding of the integral nature of all of our body systems, including the oral cavity, may eventually lead to dentistry rejoining the rest of the medical profession, which in turn could even influence insurance patterns. For instance, if we can prove beyond a shadow of a doubt that treatment of periodontal disease has an impact on cardiac health, then it might be covered under medical insurance. Those are all potential directions for dentistry that argue to beefing up the internist approach in dental education.”

Regardless, she says, digital revolution is having the greatest impact on teaching. Distance learning, scanning, digital dentistry, and social media are changing the way dentistry is taught and learned. Because of the internet, curriculum is increasingly asynchronous and online. UWSoD students spend much of their fourth year working in communities, making even Skyping into class impossible with time zone and schedule conflicts. “We’ve had to totally change our teaching methods last year to accommodate that. We can have lessons online, but we try to do more thoughtful exercises, where students are given information and then have time to think about and process it,” says Gordon. “You may have seen the recent article about the death of the lecture. While it may not be dead, there’s good evidence that active-learning techniques can be far more effective.” 

Emerging tech: Digital tools, educational integration
Gordon, who is an oral pathologist, notes that dentists are expanding their use of digital tools, not just for surgical approaches, but also for diagnosis and treatment planning, and says that dentists will be impacted by advances for the foreseeable future. She’s a self-proclaimed fan of “Star Trek” and the technologies imagined in the shows and movies, and wonders how much of that could translate into real-life scenarios: “Fifty or 60 years down the road, will manual procedures be something we delegate, will they be something we do, or will robots perform them? Will we use robots or algorithms to diagnose? Even something as artistic as diagnosis may be different in the future.” Moreover, she muses if rote memorization will fall to the wayside in favor of teaching dentists to access what they need digitally, make an assessment of the facts and materials rigorously, and apply that to patient care. “That’s a concept that’s not quite fully baked yet, but I think in 10 years we’ll be further along with how we use that type of technique,” she says.

Already, dentists are on the cusp of using genetic information for diagnosis and treatment in dentistry. Gordon says, “We’re going to find that individual approaches are more possible in patient care. We’re certainly using genetic analysis more and more in pathology diagnosis, and I can see that expanding into other realms of medical care, including certain aspects of dental care. As someone who looks at oral cancer, for example, I’ve seen the impact that immunotherapy is starting to make in oral cancer care, and the impact is going to start to be felt in other aspects of dentistry, like periodontal disease, and maybe even caries. Maybe someday we’ll have vaccinations that will prevent caries that we now treat with interventions.” 

Encouraging rural practice
We wondered, does Gordon think that programs like Regional Initiatives in Dental Education (RIDE) can help ameliorate access to care issues? She says, “We have a problem with supply and demand in the right places. We have tons of dentists in Seattle and other big cities… the nice, shiny places where dental students go to school and graduate as young adults. They’re part of the community, and they just want to stay. I saw this happen in my own alma mater. I went to school in eastern Canada at Dalhousie University in Halifax, the biggest city in the region. We had people from all over, but everybody wanted to stay in Halifax when they graduated. There were a ton of dentists in Halifax, but a lot of the communities that the dental students came from didn’t have one. The same thing happens here. That’s why we love the RIDE program. It trains dentists in smaller communities, so when they graduate, they tend to want to practice in those types of communities.” 

However, she points out, many factors influence decisions about practicing, and isolation in a small community can be a deal killer for a young dentist. “Young dentists need to feel like they’re not going to be the only dentist working in a small town. They want to be part of a team, so that if they’re sick or want to take a vacation, they can,” says Gordon. “Everybody wants to have a life, and dentists are no different. They need to feel that there is a support system in place. I think community health centers play a nice role in that, but we as a society need to make sure that dentists aren’t on their own when they go to practice in small communities.”

The future of funding the UWSoD
As you may be aware, the UWSoD is in the middle of a budget crisis. With a large shortfall, much will be needed to be done to right the ship, and Gordon is acutely aware of this. “You know,” she explains, “state funding has dropped 70 percent for the dental school versus a decade ago, and Medicaid reimbursement is low. I don’t think any of us really knows what’s going to happen with that. We have to make sure that our organizational structure is realistic and our budget is balanced, and we have a lot of work going on in that area right now. It may take a while. As in dentistry, you have to have the right diagnosis before you can find the right treatment. We’re in our diagnostic period right now, and we can’t start hopping on a treatment until we have the right diagnosis. But we’re well underway with the process of righting things, and we’re already seeing improvements with the fiscal situation at the dental school.”

Dr. Bryan C. Edgar, Immediate Past President, WSDA

Changes in licensing process
Dr. Bryan Edgar is well-known in Washington for his work with the WSDA and the ADA, and at the University of Washington. Since Edgar’s service to organized dentistry has included serving as a WREB examiner for 20 years, we thought we’d approach him with our questions about licensure. 

Live patient testing has raised the hackles of dental students for years. They claim the tests cross ethical boundaries in several ways, including paying patients and forcing them to wait for treatment. While Edgar has eschewed live testing, he’s not entirely sure he agrees with the students’ din over ethics, other than in terms of the potential harm to patients through substandard care. As an example, he recounts a story about the time a candidate performed three separate treatments on the wrong teeth during a regional exam he was observing. Needless to say, that candidate didn’t pass. This highlights the quandaries of live testing: Is working on live patients necessary, and is it ethical? This has been the source of constant consternation for 50 years.

“We’re testing the competence of candidates by having them work on live patients,” Edgar says, “but would you allow them to work on your family? Probably not. That’s why I believe that live-patient testing is flawed. Canada, as you know, eliminated live testing years ago. They have the OSCE (Objective Structured Clinical Exam), a station-based exam which utilizes typodonts in the place of live patients. And while I’ve never witnessed an OSCE in person, I’ve worked side by side with many Canadian dentists and have never seen a difference or deficiency as compared to U.S. dentists. I think we’ll have a similar model in the near future, even though the exam community has been fighting this for at least 20 years.” 

Though long in the works, Edgar feels confident that an OSCE-like test will be used in Washington state, if not nationally, within the next five years. He also believes that a single standardized exam isn’t far off either, but there are other hurdles in the way, like New York’s required residency, which could delay that process. 

Residency as a path to licensure
In Washington, Gov. Jay Inslee recently signed a bill into law allowing a residency as a path to licensure, but it’s still not required. It’s only required in New York and Delaware. California, Colorado, Minnesota, and Ohio offer licensure applicants the option of completing an accredited postgraduate education program in lieu of an exam. Edgar is a huge proponent of residencies as a path to licensure, and only sees the trend increasing in the future, saying, “The advantage of a residency is that they are trained at a much higher level than when they graduated from dental school, and that surpasses the live-patient exam by light years. That’s the plus side of residencies, and it’s what allows them to replace a regional exam like the WREB. The downside in people’s minds is they worry that a director of a residency program could allow someone who is not competent to receive the certificate from the residency. I used to think that was a possible downside, but the more I see residents and their skills, the more impressed I am. It is a great alternative to a licensing exam.” 

Maintaining standards for foreign-trained dentists
But, we wondered, what about a residency program for foreign-trained dentists? Was that something Edgar would support? It isn’t, and he explains why, “CODA has an international accreditation program that most of the leadership in dentistry were opposed to when it was first envisioned. They worried that dentists with substandard training would be allowed to practice in the U.S.. However, since it was first implemented, there hasn’t been a single foreign program in the world that met the standards set by CODA.” 

The current laws in most states require that foreign-trained dentists go through a training program of a minimum of two years, and that the dean of the dental school has to certify that they meet the standard of a graduating dentist from the dental school. That’s in the ADA guidelines for licensure and most state laws, and Edgar doesn’t imagine it will change. Canada, of course, is the one exception. We have had a reciprocal relationship with accreditation since the 1960s. Dual accreditation has also allowed for hygienists trained in Canada to work in the U.S. Additionally, Canadians send a representative to every CODA meeting, and while we accredit our programs separately, we recognize the validity of the other’s accreditation standards.

Working together
Edgar knows that change can be a hard sell in the testing, but believes this is the time for real change to happen. He looks forward to having a voice in the process and working collaboratively with colleagues and academics alike to create a fair and equitable test for dentists of the future.

Dr. Jeffrey McLean, Associate Professor, Periodontics at the UWSoD

Plaque biofilm research
Dr. Jeffrey McLean teaches first-year dental students microbiology and immunology, and is a researcher in the perio department at the UWSoD who receives his funding from the National Institute of Health through the NIDCR. He studies the types and functions of the bacteria in the mouth, explores how they may cause disease and disrupt host interaction, and tries to understand what happens when dysbiosis occurs. 

Much of what McLean does is only possible because of advances in genomic sequencing. He spends his days uncovering new and novel bacteria and discovering which functions lead to disease, including caries, periodontitis, and gingivitis. He says, “A lot of what I do is genomic-based work on the bacteria that are in the plaque biofilm. With the new advances in sequencing, we now know that the average person carries about 200 different types of bacteria in the biofilm. The biofilm is everything bacteria excrete to hold themselves together: sticky substances, extra cellular DNA, and proteins. It’s protection, a way to store nutrients, and a way to facilitate interactions between other bacteria. Biofilms are probably the predominate form of life for most bacteria. What we know now is that the places in your mouth are all different, and there are different types of bacteria growing together in different proportions.”

It’s not common for researchers to study both bacteria that are linked with caries and periodontal disease, but it makes sense because McLean uses similar research techniques in both areas. He explains why he was drawn to this research, saying, “When van Leeuwenhoek invented the microscope, his plaque was one of the first things he looked at. What interests me is that oral plaque is the first place that bacteria were discovered, so it’s the longest, most well-characterized community of bacteria ever.” In fact, he says, many of the bacteria in our mouths today were found in the mouths of Neanderthals, as well. Exploring how the bacteria have changed over time is one of the many things he finds exciting and fun about his work as a researcher. 

Chairside sequencing
McLean was motivated to research plaque biofilms, in part, because caries should be preventable, given that they are primarily caused by the bacteria metabolism. The problem was that when he began his research 16 years ago, they didn’t know which bacteria caused caries, and they lacked the tools and techniques needed to determine what was going on in the mouth. He says, “We made advances in sequencing that helped us understand their genome, their capabilities, and gene expression, and that there was coordination between bacteria. There are certain bacteria that do certain things at certain times, and that fundamental understanding helped us target specific time points and pathways that the bacteria use to live and grow. Hopefully, we can manipulate those to keep our plaque healthy. In the future, we should be able to sequence your bacteria while you’re sitting in the chair. Caries and periodontal disease have key bacteria that are highly associated with the disease progression, so if we could identify which teeth, which sites, and where they are, we could take care of them. And we could ultimately determine if that person is likely to have wider spread systemic diseases due to exposure of certain oral bacteria based upon what we find in their mouth.”

Tech is available now
Not surprisingly, some of the technology already exists. There are nanopore sequencers that plug into your cell phone, and microbiome tests that are already being utilized in medicine. But dentistry is lagging behind. Insurance companies currently won’t cover the costs of micoribome sequencing for diagnostic purposes, and even if they did, researchers still aren’t sure yet what the tests can accurately predict. McLean explains, “We need accurate tests for a strong biomarker that indicates disease progression. We still don’t understand how caries and periodontal disease are triggered by the bacteria, so that’s what a lot of the research is focused on right now, proving that biomarkers do what we think they do.” McLean says that true implementation of today’s technology is five to 10 years off, but it’s hard to tell when fundamental research will result in something definitive. 

Other research
McLean is excited about other research happening now – including bacteria manipulation through human signaling or genetic manipulation, and identifying systemic links between overall health and bacteria in the mouth – and the work he is doing with his UCLA collaborator, Wenyuan Shi. McLean says, “He started a company based on a way to kill a single bacteria called STAMPS (specifically targeted antimicrobial peptide), which is the first microbiome therapeutic that is going through phase 2 trials. It allows us to go in and kill just one bacteria. It will be used to treat caries, we’re studying how this peptide targets one bacteria and shifts the microbiome towards a more healthy composition.”

The excitement of the future

We’ll continue covering advances as they happen, and look forward to what the future holds for dentistry, education, research, and tech advances. If you know of emerging tech that you would like us to cover, send your ideas to Rob Bahnsen at rob@wsda.org.

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