Written by Gordon Christensen, DDS, MSD, PhD, ScD Saturday, 31 January 2004 19:00
For the first time in my career, my wife and I have had the experience of drawing away from the profession for a period of time to exert our efforts to full-time, nonpaid volunteer work for our Church. Over the past 24 months, our organizations, Practical Clinical Courses and Clinical Research Associates, have functioned well under the leadership of capable staff members, offering to the profession the most up-to-date continuing education and research possible. Both of us have had to keep our dental activities directed toward the most effective methods to remain knowledgeable about the myriad changes taking place in the profession. In fact, as I have had the time to view the profession from a broader scope, the experience has taught me a great amount about where dentistry is going and where the profession should put on the brakes as rapidly as possible. I am delighted to be back into dentistry full time, and the religious leave has made me appreciate the profession even more than in the past. There is no better profession!
This article will express my thoughts on every area of dentistry in alphabetical order and make predictions about what will happen in each respective area over the next year.
DIAGNOSIS AND TREATMENT PLANNING
Unfortunately, most dentists do not accomplish complete treatment plans. Numerous maladies may result. Piecemeal dentistry is received by patients. Numerous potentially dangerous conditions may be missed; patients can be confused about what portion of suggested treatment is mandatory and what portion is elective; aesthetically oriented procedures may be omitted or missed; occlusally oriented procedures may not be adequately coordinated; and new concepts or techniques may not be offered to patients. It has been estimated from various third-party benefit plans that about one half of the dentistry accomplished in the United States is aesthetically oriented.
I suggest that readers who do not accomplish a total treatment plan on patients consider the following points and place them into practice if applicable.
•Most patients want to know the total condition of their mouth when that information is offered to them. They should be told that the mandatory treatment will be differentiated from the elective therapy. Patients accept the mandatory treatment, and if they like the result of that treatment, many accept the elective therapy.
•The technical aspects of diagnostic activity can be delegated to staff members, allowing the dentist to concentrate on clinical treatment of other patients during that time. I prefer a 1-hour diagnostic appointment, where diagnostic data collection is accomplished by staff members, and the diagnosis and treatment plan are done by the dentist during the last part of the appointment.
•In the current aesthetic dentistry age, there is no more important appointment in all of dentistry than the diagnostic appointment.
Intraoral cameras are now used by most dentists, and the changes in these devices have made them indispensable instruments for diagnostic activity. If you do not have a digital clinical camera yet, several are available for a moderate cost. The immediate observation of images, combined with storage capability, make these devices indispensable.
Rotary endodontics and the crown-down procedure are dominating this aspect of dentistry and will continue to do so. Those practitioners not familiar with the devices and the crown-down clinical concept should make these subjects a must for 2004 continuing education.
Nonmetallic posts with resin-based composite buildups have become the current techniques of choice for rebuilding endodontically treated teeth. These methods provide easy clinical procedures, aesthetically pleasing root stumps, and relatively strong tooth restorations. However, clinicians should remember that research shows metal posts provide more strength to endodontically treated teeth. Endodontics will continue to be a major need in dentistry, a significant income producer, and a procedure largely accomplished by general practitioners.
In the past 30 years, interest in this area has revolutionized dentistry. Patients want to look better, younger, more attractive, and more normal. They want white teeth. On the positive side of this interest, clinical activity in dentistry has been greatly increased because of aesthetic dentistry procedures. However, there has been a definite down side to aesthetic dentistry, including overtreatment to unsuspecting patients, excessive fees, used car salesman-type hype, and overt dishonesty about products and techniques on television, in lay publications, by dental speakers, and in dental publications. Nevertheless, the overall emphasis on aesthetic dentistry is good, and it will increase, we hope, with renewed honesty and logic.
It is anticipated that numerous aesthetically oriented techniques will increase in use, including all types of veneers, tooth-colored crowns and intracoronal restorations, bleaching teeth, orthodontics, and surgical changes in the face.
Aesthetic dentistry, despite the negative changes in the ethics of the profession it has brought, has saved the profession from takeover by managed care, and it is a wonderful addition to the activity of dentists and the beautification of the public.
If you are not restoring dental implants in your practice, 2004 is the time to incorporate that procedure into your practice. Numerous simple implant restoration systems and courses about how to use them are now on the market, and there is no longer an excuse to wait until the implant concept is refined to a greater degree. Additionally, if you are a general dentist who accomplishes a significant amount of surgery, there is no reason not to include surgical placement of implants in your practice. The risk of placing implants in simple locations is less than extracting impacted third-molar teeth, which are commonly removed by general dentists.
Implant dentistry, both prosthodontic and surgical, has stabilized at a moderate level. Cost to practitioners for implants has continued to rise, and laboratories usually charge higher fees for implant supported cases. Because of these relatively negative factors, I predict continued stabilization and low growth in this area, but I strongly suggest that practitioners realize the importance of implant dentistry and incorporate as much of this fantastic concept into their practices as their personal comfort allows.
Dentists are afraid of occlusion. Despite approximately one third of the population having bruxism/clenching and the resultant tooth destruction and the rampant presence of temporomandibular joint dysfunction, this area of dentistry continues to be practiced by a hardy, biologically oriented group of practitioners. Recent years have brought renewed interest in the long-available, muscular-oriented occlusion concept. Because of the commercial emphasis in this occlusion orientation, there will be continued interest in the area. However, there is extreme controversy about what concept of occlusion is correct, and I do not see any relief to that controversy.
After many years as a practicing prosthodontist, teacher, and researcher, and experimentation with almost all concepts of occlusion, I can candidly state that it is not the concept of occlusion that allows success; it is the knowledge and experience and the clinical skills and honesty of the clinician that are important factors to success with occlusion.
Operative dentistry is an area that confused prognosticators, who predicted a few decades ago that dental caries would be eradicated by now. How wrong could they have been? Not only has dental caries not been eliminated, it has increased in the class V and class VI (incisal edge) areas. Granted, there have been some reductions in childhood caries. However, dental caries is still a very viable infectious disease that commands significant dentist time and expertise in every general practice.
It is anticipated that class I and II resin-based composite restorations will continue to be the simple posterior tooth restorations of choice of most patients despite the clinical success but aesthetic unacceptability of amalgam. Improvements in the polymerization shrinkage and wear resistance of resin-based composites are anticipated soon, increasing the acceptance and use of this material. Light-emitting-diode (LED) curing devices are now commonplace. Although most are still inferior to halogen curing devices, new developments coming soon will broaden the wavelengths provided by the LEDs and decrease the curing time of these devices.
The segment of the aging population that cannot or will not practice good oral hygiene needs restorations that provide caries prevention. Resin-reinforced glass ionomer used as a repair and/or restorative material will become more popular.
The concept of laser tooth cutting is trying to make an entrance into the mainstream of practice. However, significant improvements are needed to effect this use. Air rotor cutting is so easy and reliable that other modes of cutting teeth are not being sought actively by practitioners. The public has interest in laser technology because of the successful activity in eye surgery. Thus, lasers in dentistry have an immediate interest despite the need for further development.
Tooth-colored inlays and onlays comprise only a small amount of restorative dentistry. Improvements in these materials are making them more attractive to dentists, and slow but progressive acceptance is expected.
It is expected that operative dentistry in all of its forms will be with us for a long time, and that tooth-colored restorations will dominate and eventually take over the tooth restorative aspects of the profession.
ORAL AND MAXILLOFACIAL RADIOLOGY
Digital radiography is here! Those who have not discovered the convenience of immediate interpretation of radiographs, the storage and retrieval capability of digital radiographs, and the pleasure of no chemical solutions to contend with should look into digital radiography.
ORAL AND MAXILLOFACIAL SURGERY
Extraction of teeth has become a rarity in many areas of the United States, and this trend will continue. General practitioners accomplish most of the routine extractions, and specialists accomplish the more complicated procedures. There appear to be no major factors that will change that orientation. Implant surgery will increase somewhat among oral surgeons, where it is already a major portion of their practices.
I encourage oral surgeons to assist general dentists to become involved in simple implant surgery. As this change occurs, general dentists will find more patients who could benefit from implants, many of whom are beyond their capability, thereby increasing the overall use of implants. All 3 groups win—patients, generalists, and specialists.
Orthodontic activity continues to grow, motivated by the general trend for patients of all ages to accept aesthetic changes in their faces and smiles. More adult orthodontic procedures are being accomplished, and this will continue to increase.
Despite outcries from some orthodontists, some brave nonorthodontist dentists cross the turf battle picket lines to become involved with legitimate courses in orthodontics. Having taught occlusion in some of these legitimate multisession orthodontic courses and after observing first-hand the clinical results, I see a future for increasing involvement of nonorthodontists with orthodontic therapy after they complete acceptable orthodontic continuing education courses.
There is continued interest in use of computer-planned, sequentially used trays to move teeth. Although the concept has received criticism from some conservative groups or individuals, many practitioners continue to support and use the concept. It provides orthodontic movement without the unsightly display of metal.
Orthodontic therapy is needed or desired by a significant portion of the population, and demand for orthodontic therapy should continue to grow rapidly.
Once thought to be declining because of preventive concepts, this area of dentistry is alive and well. Increases in sugar consumption in all areas of the diet and the normal lack of oral hygiene instruction and mouth cleaning capability of children have probably contributed to the continuation of need for restoration of childhood dental caries. Additionally, some pediatric dentists are accomplishing at least some level of orthodontics. More parents are becoming aware that there are well-educated, skilled specialists available for oral care for their children, but the bulk of pediatric dentistry is still accomplished by general dentists.
Parents are interested in tooth-colored restorations for their children, especially for their anterior teeth. There is a major need for stronger, more aesthetically acceptable, relatively inexpensive, easy-to-place anterior crown or veneer restorations for pediatric anterior teeth.
Periodontists have taken on implant placement with enthusiasm. Perhaps it is because conventional periodontal therapy can be painful and disfiguring, requiring continuing treatment through life, while implant placement is relatively easy, almost always appreciated, and successful most of the time. The need for periodontists who still want to treat periodontal disease is present. As determined from surveys I have accomplished of general practitioners, I have concluded that general dentists do not accomplish much periodontal therapy other than routine scaling, root planing, and polishing, and most of those procedures are in the realm of dental hygiene.
A cure for periodontal disease has been proclaimed several times during my career to date, and no cure has been routinely effective. Conventional treatment methods are still the choice of most periodontists and the few general dentists involved with comprehensive periodontal therapy.
The potential of laser treatment for periodontal needs has received unbelievable hype, much of which has not been confirmed in practice. Although lasers have potential and patient acceptance, most periodontally oriented dentists use conventional methods.
Implant surgery will grow in periodontics, but treatment of conventional periodontal diseases will still be largely in the hands of hygienists, some periodontists, and precious few general dentists.
The aging population and some other patients in a typical dental practice need preventive concepts that are easy to use and effective. At this time, topical fluoride rinses and gels appear to be the easiest and most reliable modes to apply preventive concepts to the adult segment of the population. In my own experience, about 10% of the patients in a typical practice could use some form of aggressive preventive therapy for dental caries. These patients include (1) the aged population with degenerating digital skills, gingival recession, and general lack of motivation, (2) bulimics, or (3) any age of patients with high caries rates. A formal appointment with a dental assistant or hygienist, depending on legalities, can be used to implement this fluoride therapy. An alginate impression is made, casts are poured, and a thin tray is made while the patient remains in the office. The patient is instructed on how to use the trays and fluoride for 5 minutes at least once per day with a 1.1% neutral sodium fluoride gel. A reasonable fee for this service makes it a financially viable procedure in the office and a great service for patients.
Fluoride toothpastes have become the major dental caries prevention method in the United States. Almost everyone uses toothpaste with fluoride in it. The profound dental caries reduction effect has had a major influence on the American public and the dental profession.
Dentists and dental staff members are encouraged to provide in-depth preventive dentistry instruction to patients.
PROSTHODONTICS—FIXED, REMOVABLE, AND IMPLANT
This area of dentistry is the single largest area of income to general dentists. It has been estimated that about one third of the income of a US general dentist comes from fixed prosthodontics alone. What has caused this increase in prosthodontic needs? It is obvious that the older population with increased life expectancy, discretionary funds to spend, and a desire to look and feel better has stimulated this growth. Also, current materials and techniques allow dentists to provide restorative services that are as aesthetically pleasing and adequately functional as natural teeth in many cases.
There is a significant evolution going on at this time. Although porcelain-fused-to-metal crowns are still by far the major crown and fixed prosthesis restoration, all-ceramic crowns and fixed prostheses are growing in use a few percentage points each year. The CAD/CAM developments of the past few years have made all-ceramic crowns and fixed prostheses competitive with porcelain-fused-to-metal restorations. This growth and acceptance should continue, and there is no reason to expect that fixed prosthodontic activity will not continue its rapid and continuous growth.
Removable complete and partial dentures are still a major activity in American dentistry. Developments of new tooth forms, better denture bases, and refinements in framework metals continue to offer excellent service potential for patients. However, in my opinion, the expertise of practitioners in these areas needs significant upgrading.
Implant prosthodontics is maturing, and laboratories and dentists are gaining more expertise in these areas. I am concerned to see the continuation of some very difficult and unpredictable techniques when more simple procedures are now available. Continued efforts to educate practitioners and labs in implant prosthodontics are needed.
Maxillofacial prosthetics is a small but important portion of prosthodontics. Clinical expertise is available in most of the larger geographic areas for those patients unfortunate enough to need these services.
All of prosthodontics will continue to grow and expand in influence.
INFLUENCE OF MANAGED CARE
Managed care in all of its forms has made a major impact on dentistry, and it is stabilizing with several categories of benefit plans, some shrinking and some expanding. Dentists must decide what level of income is needed to produce a realistic optimum quality of services in their practices, then participate only in those third-party plans that allow this quality level.
It is heartening to see the slow but continual decrease in dental HMOs. In my considered opinion, these organizations have little or no place in the dental profession. The small amount of services provided to individual patients and the cost cutting necessary for practitioners to survive financially while working in these groups have caused a significant challenge for practitioners. Patients who thought they had dental care plans have been disappointed to be required to go to “preferred providers” and receive minimal or no benefits.
PPOs are growing nationally, and they will continue to do so. If specific plans offer adequate funding of procedures for you to do your normal quality of dentistry, participate in them. If they do not provide adequate funding, get out ASAP!
Indemnity programs continue to decrease slowly, but most of them are adequate in funding to allow quality services. In general, these are still one of the most satisfactory types of third-party payment concepts.
Direct reimbursement is growing slightly, but it is a minor part of third-party payment in dentistry. I cannot understand why such a logical concept is not accepted immediately by companies looking for a dental benefit plan. Direct reimbursement is without doubt the best of the third-party benefit concepts for dentistry.
Dentistry can be thankful that the ingress of the undesirable parts of managed care in dentistry was timed nearly exactly with the introduction and growth of aesthetic dentistry, most of which is elective and not funded by third-party payment plans. The result has been that dentistry has not been consumed by managed care to the degree of our colleagues in the other parts of medicine. We are surviving the managed care takeover while retaining some semblance of control of quality and dignity in the profession.
Dentistry is growing and serving the public better than ever before. In this article, the various divisions of dentistry have been considered, observing the current state of the art in each one and making predictions about the changes that are coming in the near future.
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