The Changing World of Dentistry

This interview was conducted on November 26, 2010, in Curitiba, Brazil during the Fahl Alumni V Symposium. Dr. Newton Fahl hosts this biennial symposium in Brazil featuring renowned leaders in dentistry who attract participants from around the globe. This year, Drs. John Kois and Gerard Chiche were among the distinguished presenters. They agreed, along with their host, Dr. Fahl, to answer some questions relevant to technologies, materials, and trends in dentistry. To close the interview, they shared some interesting comments relevant to dental education and to the symposium.

 John C. Kois, DMD, MSD; Newton Fahl Jr, DDS, MS; and Gerard J. Chiche, DDS

What has your real attention in dentistry these days?
Dr. Chiche: One thing that currently has my attention in aesthetics is interdisciplinary aesthetic treatment. This is a very important facet of the new Center for Esthetics and Implants which we created at Medical College of Georgia (MCG). The Center is led by members of the interdisciplinary aesthetic team who come from each department of the MCG School of Dentistry. Through this interaction, the focus is not only on aesthetics and implants; it also naturally expands into occlusion and into major rehabilitations in various combinations. Having a dedicated ceramist and dedicated faculty from different departments contribute from inception at the treatment planning, the patient management, and all phases of the treatment creates a unique level of commitment. The Georgia Health Science Center will open its brand new dental school in Augusta in July 2011, and the Esthetics and Implant Center will play a prominent role working with the different departments, their residents, and the undergraduate students. So, it is a very exciting time because we will devote significant resources to aesthetics and implants, and introduce interdisciplinary treatments to a larger number of patients, with a fully dedicated artist ceramist in the center at MCG. Many patients are willing to commit to a treatment that can span from a few months up to 2 or 3 years, and this interdisciplinary interaction allows us to enhance the quality of the treatment and deliver aesthetics at a higher level with increased support. It will be many years of exciting work.
Of course, parallel with the interdisciplinary treatment, the dental profession is witnessing the evolution of the CAD/CAM systems along with ceramic materials that can be implemented at different phases of the treatment, both chairside and in the laboratory. We will eventually see the routine implementation of digital impressions in dental schools. I believe that we will go through different generations of CAD/CAM technology until their integration becomes more universal and seamless, but we are already seeing this become integrated at the undergraduate dental student level at MCG. Also, as the dental schools at the predoctoral level are embracing these technologies, obviously the change will be profound.

Dr. Fahl: What has my attention these days is the health-promoting nature of dentistry. All the specialties and subspecialties are striving to preserve what's natural and what is sound in the oral environment. You can see this happening in all of the areas of dentistry; from surgery, going through implant therapy, to orthodontics; especially in my area of expertise, which is restorative dentistry. I see a return to minimally invasive procedures with dentists being willing to cut less teeth and to augment more, be it with composites or with porcelain with the focus being on the promotion of health.
My opinion about many of the current dental materials is that they are here to make a big difference. Actually, they are making a huge difference in terms of treatment planning and problem solving through what is referred to as responsible aesthetics. I see dental aesthetics being part of a much higher level and ethically correct approach, with dentists being able to deliver materials that are strong, reliable, and biologically compatible and provide the utmost aesthetics due to their optical and physical properties. However, the decision of whether to use a direct or indirect approach will not be based on one's ability to perform any one procedure at a higher level of excellence than another. For instance, I see many dentists who claim that direct composites are too time consuming and not as financially rewarding as a ceramic work. But, honestly, the reality is that many lack the knowledge and the skills to be able to provide their patients with sound direct composite restorations. For instance, I fully endorse minimal-prep porcelain veneers for closing diastemas, when the patients' oral habits or occlusion do not preclude such a procedure. What I do not subscribe to in this day and age is a colleague who claims to be a restorative dentist not being able to do a direct restorative procedure with composites simply because he or she lacks the knowledge to do so. What is really lacking here is proper training through hands-on courses that provide the practice needed so one can carry out anterior and posterior composites that comply with health promotion intermingled with aesthetic requisites.

One thing that currently has my interdisciplinary aesthetic treatment.
— Gerard J. Chiche, DDS

Dr. Kois: It's not just new technologies in general that have my attention; rather it's those technologies that create "disruptive" innovation resulting in different ways to think and practice. The future will be precision medicine that will more clearly separate the diagnostic and implementation phases of dental treatment with many new technologies. No matter how wonderful that these new technologies are, it's not always initially clear what they mean and how they can best be used, so there is a lot more to learn about them before we begin implementation.
I observe great frustration in many dentists who are unsure about where dentistry is going. They are anxious about how their practices will change in the very near future because the changes are occurring so rapidly. They're afraid that they won't be able to keep up, or that a significant innovation will pass them by. They aren't even concerned about the long-term future because they can't get beyond what is happening today to even think about the next 10 years. Technology is the biggest variable to the extent that these advancements can't always be supported in a single-provider practice.
Sadly, quality comprehensive care is limited in dentistry because many patients simply can't afford it. Even though we have innovative scanning and CAD/CAM technology greatly improving the efficiency of care, the cost of care is not going down. So, as long as costs remain high, few people will be able to afford the best of what we do. To deal with this real problem, we need to disrupt our old ways of thinking so our patients can have greater access to care.

With regard to the MI philosophy, what are the criteria for the selection of philosophy-appropriate restorative materials?
Dr. Fahl: There are several factors that play a role in determining which material and which technique to implement. The ability or skills of the operator is the number one parameter. This could be a dividing line between one who could perform a direct procedure versus an indirect procedure. However, I think all procedures can be taught to a level so that most dentists can perform these restorations quite comfortably with excellent aesthetic and functional results for the patient.
The second thing will be the indication of the procedure which takes into account the patient's dietary and oral habits. Smoking, and the intake of foods and beverages that might stain the restoration contraindicate composites in the anterior segment. Then, we may go from a conservative approach, which would be composite augmentation, or composite artistry, as I like to call it, to indirect restorations with MI preparations, such as porcelain veneers. Third, we must consider the patient's occlusion. In some patients we may need to resort to softer, more resilient, and stress-absorbing materials, especially when dealing with an anterior guidance that requires less abrasiveness to the opposing arch while providing proper disclusion. I have been doing direct veneers and incisal edge augmentation for many years as final restorations, and in my hands I see an acceptable life span that averages 10 to 15 years, or more. As part of my treatment planning protocol, the patient will be presented with the option of composites or porcelain, with all advantages and disadvantages of both being discussed, and then the patient partakes in the decision process. It is worth mentioning that in terms of fees, I charge the same for both a direct and an indirect veneer, and the patient is responsible for the dental laboratory fees, if applicable, separately. Of course, other minor procedures such as Class IV composite resin restorations will have proportionate fees.

What has my attention these days is the health promoting nature of dentistry.
— Newton Fahl Jr, DDS, MS

What is your opinion on the new generation of direct resins, and what are their clinical implications?
Dr Kois: I see dentistry moving toward the extensive use of direct restorations. These composite materials not only restore teeth, but also act as an adjunctive means to control occlusion. We can treat patients in an entry phase and stabilize them until then can afford more definitive indirect restorations. Direct and indirect composite approaches create the "disruption" to which I'm referring, because they allow the dentist affordable options to treat patients with financial limitations. While ceramic restorations provide longevity, aesthetics, and the like, if patients can't access them, their use is limited.
As you know, dentistry began as a profession using nearly all direct restorative procedures, but implant and ceramic technology have moved us to indirect methodologies that require much more planning and definitive decisions. These technologies require much more planning and definitive decisions from the beginning—hence, precision medicine. This has also created a bias in our thinking that direct restorative procedures are substandard. With indirect technology as a first step, what we can ultimately do for our patients doesn't have a chance because many times we've priced ourselves out of the market. If, however, we can routinely provide entry points that control health, aesthetics, and occlusion—maybe even by modifying vertical occlusal dimension—we can sequence treatment in new and creative ways. With this "disruptive" type of thinking, I think the future for dentistry can be incredibly strong.
Consider a barbecue grill. You can buy a simple propane barbecue grill that cooks just fine for $80. At the other end of the scale, you can buy a fancier propane barbecue grill for $8,000. Now, I'm not sure the $8,000 grill is not 100 times better than the $80 model. In fact, I can take that $80 grill, use it for a full year then throw it out and buy a new one; it's almost a renewable resource. I don't even have to clean it. Why can't we think about our dental services like that? If we can find ways to create more affordable entry points for patients, they may ultimately be able to opt for more definitive restorative options. The way we do it now places too many treatment options out of the reach of most patients because as soon as you have to change vertical dimension, you're typically requiring the patient to commit to at least an arch. This prices too many patients out of the market right from the beginning.
Having said that, we certainly have many more things we can do with current and emerging technology. Right now, for instance, we use scanning technology for composite occlusal surfaces that are designed and created by a machine. We can do almost an entire arch for the lab fee cost of just 2 crowns. This capability turns our treatment planning on its head and is a very different approach from how we have been thinking. Even if you look for inexpensive crown and bridge options, the problem remains that the dentist has to perform the same procedures at the chair. They still have to prepare the teeth, take or scan the final impressions. What I'm talking about is very different. It's a hybrid that blends the benefits of direct dentistry—where things can be done at the chair almost on the fly—while preserving and setting up incredible options in the future. I'm very excited about how this can be implemented because we can create fairly inexpensive ways of altering occlusion that preserve opportunities to trade up later, just like with the barbecue grill concept.

I see dentistry moving toward the extensive use of direct restorations.
— John C. Kois, DMD, MSD

You have done a lot of work with zirconium oxide restorations. Would you please you comment on this important material?
Dr. Chiche: I have more than 6 years of documented experience with zirconium oxide restorations. This technology offers 3 major advantages right now. First, we can cement crowns and fixed partial dentures (FPDs) made of this material with regular resin ionomer cements and thus keep the clinical protocol very simple. The second advantage is the ability to mask heavily discolored teeth quite predictably. The third advantage is that FPDs, of course depending on having adequate connector size and making proper patient selections, are a possible treatment protocol that is becoming a more routine procedure. However, what those 6 years of research have shown, including our publications while at Louisiana State University (LSU), is that you must utilize a high-strength veneering ceramic layered or pressed over the zirconia cores. Designed properly, zirconia cores and frameworks do not fracture, but the veneering ceramic must be carefully selected. I refer you to several CR publications where Drs. Gordon Christensen's research team identified the best performing brands, which also precisely correlates with the ones preferred by the largest dental laboratories. In my opinion, with the proper design and product selection, zirconia technology remains an important option to consider. At the same time, you have lithium disilicate technology, which is also here to stay and offers significant versatility. The way that I have been teaching my postgraduate and undergraduate students is to have them select a ceramic material on a case-by-case basis. There will be some cases which are very simply and conveniently served with zirconia-based technology and there are will be other cases that are as predictably served with other ceramic technologies, and in this fashion we feel we can offer the best option for each patient.

In indirect restorative dentistry, provisionals play an important part in the successful outcome of a case. What provisional materials do you use in your Esthetics Center at MCG?
Dr. Chiche: Bis-acryl materials have definitely taken the market by storm from an aesthetic standpoint. From a practical standpoint, we have seen undergraduate students embracing them very readily. While they do not have the flexibility or the flexural strength of acrylic resins, especially with long span bridges, they definitely offer improved aesthetics. Interestingly, I find with these materials that each brand of bis-acryl provisional material is different from the next one. They can vary significantly in terms of working time, shade, translucency, polish, and fracture strength. So, we typically end up relying on 2 separate brands to keep all necessary flexibility with different treatment options: single-unit provisionals, FPDs, or veneers. Then, there are cases where we tend to select acrylic resin for long-term resistance, especially with multiple pontics, or where we need to wait for implants to integrate in a large case. Likewise, we select one bis-acryl or the other when we conduct pretreatment aesthetic previews based on our needs in achieving certain aesthetic effects.

How does technology fit into the future of dentistry?
Dr. Kois: Diagnostically, the "disruption" created by innovative technology is significant. Right now we see the advent of biomarkers and pathogen testing and perhaps even the application of antioxidant technologies. Many concepts that we could only have dreamed about are now at our disposal or fast becoming a reality, providing patients greater options for their dental care. As it is now, the future for dentistry will always be based on risk assessment, yet there will be a significant shift from a repair to a wellness model. We are still locked into primarily a repair model, and until we change the paradigm which governs our current thinking and practice, these "disruptive" innovation technologies will be viewed as a threat by many. However, if we can understand how "disruption" can increase the capacity for care and wellness, it will not be viewed as a threat. This is such an exciting future for us and I think it will create and provide even more opportunities that we haven't even yet begun to understand.
People often talk about "thinking outside the box." I don't actually like that expression because I think that we need to build a bigger box. As we do that, the "disruption" concept that I'm talking about will create a win-win for everyone. For the dentist it will mean enhancing the level of care for patients; and for the patient it will provide more affordable options. Then the range becomes virtually unlimited. There's not any company in the world that doesn't provide entry options along with high-end options. But dentistry fails to do that well. The patients either get, unfortunately, low-quality, low-cost care or very high-quality, high-cost care. That's not a model that is sustainable in the current global economy.

Gentlemen, please share your thoughts on this informative symposium held biannually here in Brazil.
Dr. Fahl: I am very privileged to have Drs. Chiche and Kois here with me in Curitiba, Brazil, for the Fahl Center V Alumni Meeting. I think that it has been one of the best programs that we've ever hosted. I would like to defer to John and Gerry and ask them to comment on it.

Dr. Chiche: The combination of presenters here has been quite interesting to the attendees because they first heard the wonderful expertise of Dr. Van Haywood, who covered the latest techniques in bleaching techniques in depth. Then, every nuance of direct bonding was covered to the greatest degree of sophistication. Next, aesthetics related to the use of all-ceramics was covered and finally, all this information was tied together with discussion on a comprehensive diagnostic approach. So, a very wide array of treatments was covered in 3 days and it is a real testimony to what you have been able to accomplish in your community to not only have a meeting that is so well attended, but also to have so many people fly from different parts of Brazil to attend it. The level of dedication and enthusiasm that you have created in your community throughout the years is really something that I want to congratulate Newton on.

Dr. Kois: I think what's really interesting is that what unifies us is not necessarily different restorative materials, but that we all have a common philosophy on how to best manage the patient. We all agree that many times, there's no dentistry better than "no dentistry." But sometimes we have to provide treatment that may be more invasive. What I see as an important unifying factor is the priority we all place on healthcare management for our patients. I think Newton has done an incredible job in instilling that in his center.

Dr. Fahl: When I thought of putting this program together and asking each one of you, including Dr. Haywood, it was for exactly that reason. It was to have a comprehensive overview of the interdisciplinary approach that we can provide our patients. It's not just about being a prosthodontist or a restorative dentist; it's about aggregating all of the values of health-promoting dentistry into one assembly, which is what we're doing here. I know that John can relate to this because of what he has done and continues to do so well at the Kois Center in Seattle, Wash.

Dr. Kois: Thanks Newton. Yes, the Kois Center is a graduate program for practicing dentists that provides a fully integrated program. This distinction is important to me because the world is filled with isolated snippets of information traveling at speed of thought; putting that information together to create meaning and understanding, however, is more difficult. So what I'm trying to do at the teaching center is to start with the word "why?" "Why do we do what we do?"—rather than simply "How to do what we do?" If you understand the "why" in any situation, you can begin to make your own decisions.
We have to change the way things are implemented to our profession because, at the moment, if ideas just come from one person, that can be very dangerous. Icons have the power to influence and the power to mislead. So I'm trying to be much more careful about where the "why" comes from and how the understanding is achieved. I may not always be on the cutting edge, but I'm trying to be very conservative so we don't have to backtrack on what I have taught. We can't afford for our students to regret what they learned at our hand. Dentists often have a real problem with guilt when dealing with failure. We often question our role in an unintended consequence. That phenomenon mitigates the great joy we can derive from this wonderful profession because while we work hard to do the best for our patients, we take it personally when things go wrong. At the Kois Center, we have made it our mission to understand much more about biologic and product concerns. Failure isn't always dependent on the operator, and in our research work we are committed to finding out why.
Dr. Fahl: I want to thank our presenters for their commitment to be here for this tremendous program, and on behalf of everyone who presented here, want to thank Heraeus Kulzer for their support. Not only because it's a company that provides the means for making a program like this possible by helping to bring renowned speakers, but I want to thank them for being committed to education, first and foremost.F

Editor-In-Chief's Special Acknowledgement
Dr. Adams would like to thank Mr. David Porritt for conducting this interview on behalf of Dentistry Today; thanks also to Heraeus Kulzer for their support in this very special endeavor; and above all, personal thanks and kudos to Drs. Fahl, Chiche, and Kois, without whom none of the shared wisdom and inspiration presented here for our readers would have been possible.

Dr. Kois received his DMD from the University of Pennsylvania, School of Dental Medicine and certificate in periodontal prosthodontics with an MSD from the University of Washington, School of Dentistry. He maintains a private practice limited to prosthodontics in Tacoma and Seattle, Wash, and is an affiliate professor in the graduate restorative program at the University of Washington. He is the past President of both the American Academy of Restorative Dentistry and Amercan Academy of Esthetic Dentistry, and a member of numerous other professional organizations. In addition, he continues to work with restorative dentists at the Kois Center, a didactic and clinical teaching program. Dr. Kois continues to lecture internationally and is a reviewer for many journals. He is the editor-in-chief for The Compendium of Continuing Education in Dentistry. Dr. Kois is the recipient of the 2002 Saul Schluger Memorial Award for Clinical Excellence in diagnosis and treatment planning, and received a Lifetime Achievement Award from both the World Congress of Minimally Invasive Dentistry and the American Academy of Cosmetic Dentistry. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Kois reports no disclosures.

Dr. Fahl received his DDS degree from Londrina State University in Brazil, in 1987. In 1989 he received the certificate in operative dentistry and master of science degree from the University of Iowa. After returning to Brazil, he settled in Curitiba, where he maintains a private practice emphasizing aesthetic and cosmetic dentistry. He is a member of the American Academy of Esthetic Dentistry and founding member and past president of the Brazilian Society of Aesthetic Dentistry. He is a MCG-Hinman Foundation fellow. Dr. Fahl has published several articles on direct and indirect bonding techniques. He is on the editorial board of the European Journal of Esthetic Dentistry, Practical Procedures & Aesthetic Dentistry, and Spectrum. He is an active consultant for several manufacturers in the development and refinement of new materials and techniques. He can be reached via e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Fahl reports no disclosures.

Dr. Chiche is the Thomas Hinman Endowed professor and director of the Center for Esthetic and Implant Dentistry at the Georgia Health Sciences University School of Dentistry in Augusta. He received his dental degree from Paris 7 University in Paris, France, and his degree in prosthodontics from the Louisiana State University in 1979. He is a past president of the American Academy of Esthetic Dentistry and the author of 2 textbooks, Esthetics of Anterior Fixed Restorations and Smile Design (Quintessence). He serves as adjunct faculty at the Pankey Institute, in Florida. He is the recipient of the 2003 Educational Community Achievement Award of the Seattle Study Club for best dental educator of the year, the 2003 Louisiana State University Alumni Award, and the 2007 recipient of the Greater New York Academy of Prosthodontics Foundation Distinguished Lecturer Award. He can be reached via e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Chiche reports no disclosures.

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