The times they are a-changin’

Gary M. DeWood, DDS, MS

Dentistry is a profession with a history of restoring function to masticatory systems injured or destroyed by disease. Function was the inevitable focus of those whose natural teeth were just a memory.

While functional and esthetic concerns are, in most cases, inextricably linked, it’s readily apparent from the images associated with the literature of the past 150 years that esthetics was not a driving force in dentistry. Times have changed.

I began my dental career in 1976. At that time, gold served as the undisputed standard for dental restorations. My training included waxing, casting, and cutting windows in them for esthetic (read as “white”) facings.

Porcelain denture teeth had the potential for exquisite esthetics even then, but their attachment to a denture made them less than desirable. Few patients complained about the gold.

Patients today demand restorations that mimic or improve what they had when they walked into the office. While excellent arguments can be made for the preferred use of gold restorations in many of the applications in which ceramics are used, most patients — indeed most dentists — are not swayed by this logic.

They are quite willing to accept any increased risks associated with the ceramic restorations because they look like teeth. Times have changed.

I ran a PubMed search for dental tissue generation, and I was astounded by the results. An August 2010 article in Developmental Biology is titled “Induction of human keratinocytes into enamel-secreting ameloblasts.”

Even more interesting is an article from Trends in Cell Biology titled “Stem-cell based biological tooth repair and regeneration.” Researchers are growing teeth from tissues harvested from the patient for whom the tooth is grown. Future archaeologists will undoubtedly wonder why, for a short period in human history, there were thousands of people with metal devices implanted into their jaws as support for dental prosthetic devices.

They will note a change in these devices to a biological mimetic system, and then note that they disappeared from use as the mimic is created from the actual recipient.

I believe we will see implant companies creating products from bioengineered dentin in my lifetime, and I hope I live long enough to see it become individualized. Imagine a world in which the implant is a root form with the same DNA signature as the patient’s. I am pretty certain patients will readily accept having their tissue placed into their bodies, especially when that tissue can be engineered to perfectly replace what was lost or never developed.

What about patients for whom implants are not a necessary part of the treatment plan? What would happen if the restorative/esthetic dentist had the ability to design and grow teeth from a basic tissue sample taken from the patient?

My first reaction to this thought was that no one in their right mind would have teeth removed and ideal teeth implanted if they could have things changed with porcelain or composite. Right?

There was a time not long ago when much of what we consider routine today was not just considered impossible, it was not considered at all. The speed of change in health care and biological understanding moves faster than the speed of light. From my vantage point, it continues to accelerate.

The esthetic dentist in 2075 may be able to bank some stem cells from gingiva and generate on demand any tooth desired with improvements to the original design reprogrammed into the DNA. Want to have longer incisors? Sit back, relax, and I’ll grow you a couple. The times are changing.

As I think about what dental esthetics might mean fewer than 100 years after my graduation from dental school, I am reminded of something one of my mentors and heroes — one of the smartest men I have ever known, the late Dr. Parker Mahan — told me a few years ago.

He was slowing down a bit after more than 50 years in dentistry, but his curiosity and capacity for learning burned as bright as ever. He probably forgot more during our conversation than I will ever learn.

“Gary,” he said to me, “my only regret about where I am in my career is that I am now certain that I can not live long enough to learn everything I want to know, but I’m not going to stop trying.”

Amen, Dr. Mahan. The times are always a-changin’.

Gary M. DeWood, DDS, MS, earned a DDS from Case Western Reserve University in Cleveland, Ohio, and an MS in biomedical sciences from the University of Toledo College of Medicine. He serves as executive vice president for curriculum for Spear Education, teaching and practicing in Scottsdale, Ariz. Contact him at [email protected].