Dentistry Today is pleased to present an exclusive interview with Dr. Harold C. Slavkin, one of the dental profession’s most prominent leaders in the areas of education and research. Dr. Slavkin is Dean and G. Donald and Marian James Montgomery Professor of Dentistry at the University of Southern California School of Dentistry, and former Director of the National Institute of Dental and Craniofacial Research. In this interview Dr. Slavkin shares his insight into the future of dentistry, including his predictions in the areas of education, research, patient and community oral health, and advocacy for oral health in the 21st century.
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DT: How will the changing demographics of the United States influence dentistry and dental education in this country?
Dr. Slavkin: The United States continues to grow in population, now approaching 300 million people, yet one third of the total population does not have dental insurance, lacks access to oral health-care, and most often represents very poor or “working poor” people. Within the underserved populations, poor children under age 5 and mature adults over 65 years of age are highly vulnerable to chronic diseases and disorders. For example, more than 20% of children under 5 years of age live below the poverty line.
The number one chronic disease of children is tooth decay. Tooth decay significantly inhibits school readiness and school attendance. Issues with access and quality of care also are apparent when considering periodontal disease, oral cancer, chronic facial pain, patterns of edentulous people in America, early childhood caries, and low-birthweight premature babies and the oral hygiene of the pregnant mother. In this time and environment of increasing oral health disparities, new demands of access and dental care will likely become “politicized” with varying consequences. Who will provide comprehensive care for these vulnerable subpopulations? Is there an implied “social contract” between the dental profession and the larger society? Should oral healthcare be treated as a commodity or an integral part of overall healthcare?
DT: How will the completion of the Human Genome Project and soon the oral microbial genomes affect dentistry?
Dr. Slavkin: Science and scientific discovery are the fuels for technology and clinical applications to oral healthcare. The derivatives from human and microbial genomics will include new and innovative “point-of-care” diagnostics, new therapeutics, and new biomaterials coupled with tissue engineering. Imagine clinical approaches to regenerate enamel, dentin, cementum, and bone! Imagine point-of-care saliva diagnostics to determine risk assessment, biomarkers for disease, and assessment of treatment outcomes! Imagine innovations to regenerate teeth! Imagine tests to determine who is at risk for diseases and disorders!
Why am I so optimistic? The past 50 years have demonstrated more change than the previous 500 years, and those 500 witnessed more advances than the previous 5,000 years. The rate of change is enormous, and this is reflected in genomics, proteomics, and the resulting biotechnology applied to healthcare. James Watson and Francis Crick, based upon the extraordinary x-ray crystallography data of adenoviral deoxyribonucleic acid (DNA) done by Rosalind Franklin, discovered the structure of the double helix and suggested rules for replication and expression of genetic information. This moment in history (April 1953) catalyzed the transformation of biology to become an “information science.” Thereafter, the genetic code was discovered, and eventually the unity of genetics throughout the world of microbes, plants, and animals was established.
More recently, the Human Genome Project was completed in October 2004. Humans contain approximately 25,000 genes encoded within 23 pairs of chromosomes located within the nucleus of every somatic cell in the body. Today, we know that the largest genetic variance between any 2 people on the planet Earth is 0.1%, or 3 million nucleotides or bases (A, adenosine; T, thymidine; C, cytosine; G, guanosine) of the 3.2 billion nucleotides that comprise the human genome. Tools called SNPs (single nucleotide polymorphism) have been created to literally find a needle in the haystack or a nucleotide variance within 3.2 billion choices. We can now detect subtle differences that can be informative for disease detection or progression of therapy. Today we now have the “parts list of life.” In tandem, hundreds of microbes (viruses, bacteria, and yeast) were redefined in terms of their genomes. Animals ranging from fruit flies to philosophers were also completed. Human and microbial genomics are now nested within complex databases within the National Library of Medicine (nlm.nih.gov).
Importantly, all human diseases and disorders are “genetic”—either single gene misspellings, errors, or deletions (Mendelian), or multigene, meaning multiple gene-gene and gene-environment interactions such as those that characterize chronic diseases including cardiovascular diseases, cerebrovascular diseases, osteoporosis, arthritis, autoimmune diseases, periodontal diseases, and much more. Human Mendelian genetic diseases (single gene defects) are defined and databases established. Hundreds of bacterial species’ genomes that live within biofilms on tooth surfaces, catheter surfaces, and dental implant surfaces (and beyond) have now been completed. These human and microbial genomic databases are now “new frontiers” for individualized drug discovery and innovations for targeted drug delivery. A new field of pharmacogenomics has evolved.
For example, Streptococcus mutans is a major microbial cause of dental caries. We now know that strep mutans is transferred from caregiver to infant during the first few years of life. We can create approaches to prevent transfer; we can target gene therapies to inhibit intracellular pathways within bacteria that regulate acid production as a by-product of carbohydrate metabolism; we can inhibit mutans aggregation; we can target the “discrete killing” of one species of bacteria within the oral biofilms; or we can pursue other clinical approaches that sound almost like science fiction but they are not science fiction.
From another view, we can plan to utilize stem cells, growth factors, scaffolds, and the fundamentals encoded within the human genome to design and fabricate human tooth organs for tooth replacement. Tooth regeneration has become a scientifically valid goal for the near future. In fact, several universities are planning strategies to realize the goal of tooth regeneration for the near future. Imagine, the existing scientific knowledge is now available that encourages and justifies pursuit of tooth regeneration. This would be a logical next step beyond current dental implants.
Now in the 21st century we are already experiencing enormous changes around the world. Our current century will surpass the past for remarkable advances in the human condition. We are learning and eventually we will formulate strategies that optimize the human experience for all people around the world. The current few decades before us will surely surpass the 20th century with an incredible avalanche of scientific and technological discoveries, as well as economic, social, and political change on a scale never experienced before in human history. The biological and digital/information revolutions are rapidly converging with clinical dentistry and medicine. I anticipate profound improvements in health promotion, risk assessment and disease prevention, as well as in the diagnosis, treatment planning, treatments and therapeutics, biomaterials, and outcome assessments within healthcare. Genomics, proteomics, metabolomics, and pharmacogenomics are rapidly changing how we think, what we teach, and what we practice.
DT: With new science and technology rapidly advancing, how will the 4-year DDS curriculum be influenced?
Dr. Slavkin: In my opinion, the profession of dentistry has evolved and is now mature enough to acknowledge that a 4-year curriculum is not sufficient for a 21st century dental education. We must decompress and revise the current curriculum and we must add an additional and required fifth year—a so-called 4 + 1 program, with the fifth year being a mentored, community-based program that has the capacity to increase access to care, reduce oral health disparities, and increase clinical competencies for our graduates. Dental school graduates need most of the core competencies of medical school graduates plus more.
The term dentist must be comparable in substance to terms such as dermatologist, internist, otolaryngologist, anesthesiologist, neurologist, cardiologist, and ophthalmologist; meaning that all health professionals must be grounded in comparable biomedical science and technology education. We must make a commitment to upgrade and reinvent ourselves with new scientific and technological advances. Becoming a competent beginning clinician requires licensure processes that can be regulated by universities (my preference) or by state or national regulatory agencies. Thereafter, the public should have confidence in the sustainability of its health workforce through recertification requirements at a state or national level. Rapid changes coupled with accelerated scientific and technological changes by their very nature require major reforms and revisions in dental as well as medical education, and should be considered as a learning continuum. Learning is living!
Another vital need is to increase the education and training of our student learners in the field of leadership and management of dental practices. Being a health professional as well as a business owner, my thought is that we would first model this strategy in several states, evaluate the advantages or disadvantages, and craft policy that can influence a national agenda.
Further, we need to model a profession that is “team-based,” meaning general and dental specialties, dental hygiene, dental assisting, and dental technology learn and work together to foster superb and comprehensive healthcare for the populations that they serve. It also means much more porosity and redundancy among medicine, dentistry, pharmacy, nursing, and the allied health professions, especially occupational therapy and physical therapy, to optimize health and wellness for all Americans.
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DT: Do we need major reforms in dentistry? If so, what might those be?
Dr. Slavkin: My sense is that becoming an oral health professional is more complex, more intellectually demanding, and more technique-sensitive than during the 20th century. Today, the content or curriculum of dental education includes the range of themes and topics that extend from conception through hospice care. In addition, educators emphasize that we wish to enable our learning students to know the “thinking” as well as applications. We are advocates of science as well as technology. Today, human psychology and other human behavioral sciences are part of becoming a dentist or a physician. Today, understanding “the other,” or how to manage cultural diversity, has become an imperative for all health professions. We also must embrace “service-learning” clinical venues that provide experiential learning within environments that present the human condition from prenatal care through hospice care.
We fully appreciate that the mouth is part of the human body. Oral health is associated with systemic health, and oral diseases are associated with systemic diseases. A contemporary dental education needs to address these issues in depth. And our university-based schools of dentistry must engage in shaping the future through translational and clinical research. Our university faculties need to engage in life-long learning for themselves, and also nurture continuing professional education for graduates.
DT: There is an increased demand for young people to become dentists. Can the growing population of America accommodate the applicant pools? How?
Dr. Slavkin: This is a very interesting question. My short answer is yes. Today, America consists of 300 million people. Our net growth is approximately 1.5 million people per year. American dentistry is extraordinary in addressing the oral health issues of two thirds of the population. Today, our US dental schools graduate approximately 4,000 dentists per year; almost 30% pursue some type of advanced training or specialty training after graduation. Curiously, more dentists retire per year than graduate from dental schools. Today’s dentists and their teams—dental assistants, dental hygienists, and dental technologists—are prepared to offer sophisticated solutions for diseases and disorders as well as enhancements for aesthetics and function. Arguably, American dentistry is the best in the world. Meanwhile, 110 million people do not have dental insurance, and nearly one third of the total population does not access available dental care for a variety of reasons that include finances, education, cultural issues, and core values.
From my vantage point here in California, we need to develop models that will provide oral health to all people. Obviously, this raises a complex question. For example, is the oral healthcare of preschool children a commodity or should it be an entitlement? As citizens, does each of us want to optimize the health and education of our nation’s children? Depending upon our national, state, city, and personal oral health policy decisions, we could easily engage significantly more well-educated dental professionals to improve the oral health of all Americans.
DT: Any final comments about what the future holds for dentistry?
Dr. Slavkin: It is readily apparent that our nation will continue to grow at a rate of 1 to 2 million (net gain) per year—presently we are 300 million people. It is further evident that clinical dentistry as it is currently configured has an economic growth of 6 to 9% per year, and this is generated by providing outstanding oral healthcare to only two thirds of the American public. It is further valid to assume that digital “dentistry” will continue to advance and become “better, faster, cheaper, smarter, and smaller” due to nanotechnology. New, better, and smarter technology will continue to emerge and influence the practice of dentistry and the depth and breadth of dental education. This will be further challenged by the emergence of molecular dentistry and medicine, the new pharmacogenomics, and patients’ increased sophistication gained through access to the Internet and beyond.
