Many changes are taking place in the dental profession, some of them very significant. It is a time of difficult decision making for dentists as they attempt to determine if they should replace successful and well-proven procedures of the past with the new concepts being introduced. Some of the innovations are physical materials, techniques, or devices, while others are conceptual. This article discusses numerous small and large adjustments in the profession that appear to be ongoing and are expected to be permanent. I know that there will be disagreements among readers about whether these paradigm shifts are actually taking place, and I apologize to any reader who is offended by my observations that his or her pet area may be waning. The comments are based on my experience constantly observing thousands of general dentists and dental specialists, as well as manufacturers and retailers around the world in numerous countries.
THE CHANGE FROM “NEED” DENTISTRY TO “WANT” DENTISTRY
The most influential, ongoing paradigm shift in dentistry began about 30 years ago with the initiation of several academies aimed at aesthetic/cosmetic dentistry. It is easily seen in today’s continuing education courses, new materials and techniques, and advertisements to the lay public. A major portion of the dental therapy accomplished in developed countries is no longer oriented toward pain relief, breakage of teeth, or tooth loss. It is directed toward elective procedures that improve patients’ appearance, thereby increasing their self-esteem, social interaction, and enjoyment of life. This change in dental therapy has caused a “boom” in demand for dental services and has compensated for the reduction in needed services caused by the decrease in dental caries of childhood and adolescence. It is expected that the ongoing change from “need” dentistry to “want” dentistry will continue to accelerate and increase.
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Figure. The author demonstrates the infuence of implants on fixed and removable prostheses. |
The obvious increase in dentists’ income from the demand for “want” dental procedures is a negative factor. It is evident that there is an increasing necessity for dentists to develop honest treatment plans aimed at patient needs as well as patient wants, and not oriented toward personal financial gain. Patients should have a clear understanding of which suggested procedures in treatment plans are in the “need” category and which are in the “want” category. Elective dental therapy should be offered to patients only after informing them of the elective nature of the treatment and discussing the alternatives for other procedures or no therapy at all.
RELATIONSHIP OF PERIODONTAL DISEASE TO SYSTEMIC DISEASES
In the last several years, the literature has contained references to the possible link between various serious systemic disease conditions and periodontal disease. Much has been written on this subject, and conclusions continue to be made, regardless of their accuracy. Continuing studies need to be accomplished to substantiate the relationship further between systemic disease and periodontal disease. Assuming that the theories are correct and predictable relationships exist between periodontal disease and systemic health, the significance of the findings are of vital importance.
Although much has been written and prognosticated about this subject, general dentists have not been influenced to significant observable action to date. Educators and associated organizations should devote effort to stimulate the profession to use these relationships to motivate patients to treat periodontal disease.
DIGITAL RADIOGRAPHY
Many dentists have embraced digital periapical and bite-wing radiography with enthusiasm. The movement away from conventional dental radiography has been spread over several years and has been welcomed by many, but the change has not yet been universally accepted. In spite of some dentists’ reluctance to change to digital radiography, its numerous advantages make it apparent that the movement to digital, although perhaps peaked at this time, will continue and expand to gradually encompass all periapical, bite-wing, panoramic, and other types of radiographs.
Digital radiography has many advantages, which have made almost all users pleased with their conversion to digital from conventional radiography. Among them are immediacy of image observation, easy storage of images, ability to enhance images for better diagnostic purposes, elimination of standard radiograph developing tanks, devices, and solutions, ability to transmit images electronically to any desired recipient, and a reduction in radiation to patients. It is now apparent that the acceptance of digital radiography for periapical and bite-wing radiographs is spreading into panoramic and other types of oral and facial radiographs. Three-dimensional digital radiography is now available and is on the horizon for typical practitioners.
Dentistry is experiencing a major change from conventional radiography to digital. The change is difficult and expensive for dentists, but the eventual total conversion will benefit both dentists and patients.
SMALL-DIAMETER IMPLANTS
There is no question of the value of conventional diameter and length root-form implants. Dentists who have accepted their use over the last several decades have changed their entire orientation relative to prosthodontic practice. However, there have been some unfortunate realities relative to the use of conventionally sized dental implants. The cost of placing the implants and completing the subsequent restorative therapy often limits implant use only to affluent patients. Additionally, many patients do not have enough oral bone to allow placement of the nearly 4-mm diameter and approximately 12-mm to 14-mm or longer conventional root-form implants, and many patients will not accept or cannot afford grafting of bone from some other part of their body to augment the natural bone that is present. These conditions do not let implant dentistry serve the general public as routinely as would be desirable.
Over the past 10 years approximately, small-diameter implants, also called narrow-body implants or “minis,” have been accepted for “long-term” use. These small implants, usually from 1.8 to approximately 3 mm in diameter, can be placed in minimal bone that could not support conventional-diameter implants without bone grafting. Small-diameter implants can be placed in bone with a minimum of about 3 mm in a facial-lingual dimension and 10 mm in a crestalapical dimension. When placed correctly in healthy patients with adequate bone, the success of these small implants is rivaling the success rate of conventional ~4-mm or more diameter implants. They are placed in a simple, noninvasive manner, usually without the necessity to make a soft-tissue flap. The relative ease of use of small-diameter implants combined with the comparatively inexpensive cost and patient satisfaction observed have allowed patients previously denied implant therapy to have the benefits of this service.
More long-term research on small-diameter implants is needed, but it appears that this implant concept will widen and expand the use of implants and reduce the use of more aggressive and expensive procedures.
MAKING DIGITAL IMPRESSIONS
The use of conventional vinyl-polysiloxane and polyether impression materials for making dies and casts will eventually be replaced by digitally scanning tooth preparations in the mouth and digitizing the data for dental laboratories. In recognition of the up-coming introduction of a new in-office scanning device from 3M ESPE is the reality that the conventional impression is on the way out. As with any new concept, practitioners’ acceptance of this technique and the eventual integration into routine dental practice will require an unknown time period, but the possibility of this concept replacing conventional impressions appears to be inevitable.
MINIMALLY INVASIVE DENTISTRY
New organizations, such as the World Congress of Minimally Invasive Dentistry, are achieving success, and the enthusiastic interest of some practitioners is apparent. This movement encourages and teaches minimally invasive procedures in all areas of dentistry. Numerous dental schools are accepting and teaching the concept. To many frustrated dentists, such conservative activity is a welcome relief in light of overt and excessive “over treatment” observed in dental publications and practice. The movement encourages minimal cavity preparations, conservative periodontal therapy, remineralization of lesions on teeth, and all forms of preventive therapy, to name a few of the areas of minimally invasive activity.
ENDODONTICS VERSUS TOOTH EXTRACTION AND IMPLANT PLACEMENT
Although it is currently not as evident as other paradigm shifts, the profession is engaged in the early stages of this ongoing transformation. A definite indication of the change is the inclusion of implant surgery into endodontic graduate programs. I have surveyed numerous dental continuing education audiences, and have found the following facts. The majority of dentists attending these courses have had at least one tooth treated endodontically. When polled concerning the lack of signs or symptoms in the affected teeth, about half of the dentists report that the endodontically treated teeth still have some occasional pain, sensitivity, or awareness of the presence of something different about the tooth. This sample should indicate the relative best expectations of endodontic therapy, since the recipients of the therapy are dentists treated by colleagues.
In similar audiences, I have queried about those who have had implants placed in their own mouth. Up to one fourth of the attendees in any dental continuing education audience have had an implant placed. When asked about occasional pain, discomfort, awareness, or other signs or symptoms, almost nobody complains of such conditions. Into what conclusion am I leading you? In my opinion, and obviously lacking long-term clinical evidence, the relative positive success of implant therapy over the last 20 years versus the success of conventional endodontic therapy often encourages dentists to remove suspect teeth and replace them with implants. The trend will continue.
ENDODONTIC FILLING MATERIALS
The previous section expressed the lack of satisfaction with currently practiced endodontic therapy, as reported by dentists in continuing education courses. As a prosthodontist, I have seen many situations where endodontically treated teeth look excellent from a radiographic standpoint, but they have long-term lingering postoperative pain or other discomfort. Sometimes, such cases do not respond to retreatment, and they must be removed before accomplishing any restorative oral rehabilitation.
In relatively short-term research, the introduction of the product Resilon, available from Pentron Clinical Technologies as Epiphany or from SybronEndo as Real-Seal, and glass ionomer root canal filling materials has marked a departure from the long-used gutta-percha concept. It appears that canals sealed with Resilon, and for some reason not restored subsequently, still have a resolution of the periapical lesion, while it is common knowledge that canals filled with gutta-percha and not restored subsequently often have no resolution or a worsening of the periapical lesion. In my opinion, the endodontic community should look carefully at the actual clinical success of endodontic therapy and determine if it is time to change to another concept or material that seals endodontic canals to a better degree. A paradigm shift to nearly 100% success would be welcomed.
CAD/CAM-DEVELOPED ZIRCONIUM OXIDE-SUPPORTED CROWNS AND FIXED PROSTHESES VERSUS PORCELAIN-FUSED-TO-METAL
This paradigm shift is well along, and it is looking very positive. Although PFM restorations have served the profession for about 50 years, their use is being challenged strongly by the zirconium oxide-based crowns and fixed prostheses. Products such as Lava from 3M ESPE, Cercon from DENTSPLY, Everest from KaVo, and e.max from Ivoclar Vivadent are making a significant impact on the fixed prosthodontic market. Although more long-term research is needed, dentists and patients alike are supporting the change from metal-supported ceramic-covered restorations to these strong all-ceramic restorations. Many products from various parts of the world are involved in this area of change; most of them are coming from outside the United States. The advancements are coming very fast in computer-driven milling of zirconium oxide substructures, and new fired ceramics and pressed ceramics are being developed to cover the zirconium oxide. This change is happening rapidly, and in my opinion, it will gradually replace PFM restorations.
OFF-SHORE DENTAL LABORATORIES
Unknown to many US dentists, a significant portion of their dental laboratory work is coming to them from developing countries through their regular dental laboratories. The current percentage is estimated to be somewhere around 10% to 20% or more. The low cost of producing dental laboratory work in developing countries will change the American dental laboratory area. It has been estimated that the trend will continue to erode the US laboratory market for an undetermined period of time. However, as the developing countries continue to develop, they too will have workers de-manding higher salaries and better working conditions. Whether or not the trend to off-shore dental laboratory work will have a long-term significant negative effect on the laboratory industry in the United States is still to be determined, but it is apparent that the trend will continue.
“PLASTIC ORTHODONTICS”
The innovative product Invisalign (Align Technology) has attracted the attention of thousands of orthodontic specialists, pediatric dentists, and general dentists. It allows or-thodontic movement of teeth without significantly compro-mising aesthetics during treatment. Acceptance has been very good but not unanimous. The product is allowing aesthetically acceptable treatment of minor to some moderate orthodontic situations with predictability and observable patient satisfaction. Orthodontic patients have welcomed the simple treatment of orthodontic cases without unsightly brackets, bands, and wires. Assuming new developments and innovations will continue to come in this area, I predict that this concept will continue to grow and prosper.
ADULT DENTAL CARIES
According to predictions made by dental leaders, researchers, and educators several decades ago, caries was supposed to be cured by now. The caries activity in childhood and adolescence has decreased. However, the increase of dental caries in mature adults is obvious. As a result, the need to accomplish difficult operative dentistry procedures and the development and use of preventive restorative materials have also increased. Dental caries is shifting from a childhood and adolescent condition to a disease primarily in mature adults. Will this shift continue? It appears that as life expectancy continues to increase, it is anticipated that the adult dental caries challenge will also increase.
AMALGAM VERSUS RESIN-BASED COMPOSITE IN CLASS II LOCATIONS
This paradigm shift has been going on for many years. Although amalgam continues to be supported by the American Dental Association and other dental and medical organizations, fewer dentists are using amalgam as a routine restorative material, and a significant portion of US dentists do not use amalgam at all. Every year, as resin-based composite restorative materials have become better, more dentists have put aside amalgam as their primary restorative material. It is anticipated that as amalgam use is reduced, resin-based composite use will grow, dentists will become more competent in placement of resin-based composite, and eventually amalgam use will be replaced with resin-based composite.
SUMMARY
It is a time of revolution and innovation in dentistry. Many of the ongoing changes are significant, while others are less influential. I have discussed numerous observable and inevitable paradigm shifts. Dentists are advised to note the ongoing trends, become educated about them, evaluate the importance of the changes in their individual practices and to their patients, and to integrate these changes into practice.
Dr. Christensen is a prosthodontist in Provo, Utah, and is director, Prac-tical Clinical Courses and co-founder and senior consultant, CRA Foundation. He is an adjunct professor at Brigham Young University and University of Utah. He can be reached at (800) 226-6569 or info@pccdental.com.
