Oral Health Board Reflects on 150 Years

Jordan Soll, BSc (Hon), DDS, Dip. ABAD
As Canada celebrates it’s 150th year and reflecting back on the changes and developments in dentistry, I believe two of the greatest advancements in our profession are:

1) Total Etch–Total Bonding
2) Digitization

In 1987, dentistry changed profoundly when Fusyama introduced the world to “Total Etch – Total Bond” and the beginning of todays’ current concepts of cosmetic dentistry were born.
This included acceptance of posterior composites as a viable replacement to amalgam as well as bonding thin shells of porcelain to the facial surfaces of teeth to correct aesthetic deformities.
By advancing the concepts of adhesive dentistry, dentists today are able to conservatively restore teeth in a fashion that allows for far less tooth reduction while delivery a superior looking restoration.

The introduction to digitization as an extension to the advancements to personal computerization has allowed for immense benefits for dentists. Digital radiographs allow for far greater image clarity and speed in which films can be viewed.

An extension of these images is enhanced with the introduction of CBCT radiographs, which allow objects to be viewed in 3 dimensions. Moreover, digitization has enhanced the way object replication occurs in the process of scanning and milling for the fabrication of crowns and implant placement. In addition, digitization assists in office management in the form of removing vast amounts of paper records in the form of a paperless/chartless office. This allows for all records to be stored electronically and easily retrieved, resulting in less of a footprint needed for records/charts and streamlining communications between offices and within offices.

Les Rykiss, DMD
The most significant development for me in the last 150 years is very difficult to narrow down to one event. As cosmetic editor for Oral Health, the most significant events for me that have changed dentistry forever are:

1. The invention of composite resin material and the vision of Dr. Irwin Smigel to place that esthetic material on teeth to change the look of a tooth. This revolutionized the mindset of dentistry from being the restoration of broken down teeth, to reinventing patient’s smiles. Call it the beginning of the esthetic revolution. Dr Smigel paved the way for the cosmetic future of dentistry. For many years, this has led to newer materials and methods being developed in order to enhance the smiles of our patients.

2. The other significant change in dentistry for me is the age of digital dentistry. This includes digital impressions, cad/cam design and fabrication of restorations, all of which makes dentistry more efficient and reduces restorative timelines for our patients. For many years, the restorative process that included laboratory manufactured crown and bridge was a multiple appointment process. Now with the advent of digital dentistry, patients can have teeth restored in one single appointment. Dentistry is much more immediate and efficient for both dental offices and for patients.

Gary Glassman, DDS, FRCD(C)
Vince Lombardi so eloquently stated, “Practice does not make perfect. Only perfect practice makes perfect.” In other words, we can perform a procedure repeatedly over and over again and not obtain the expected outcome for success. We must continually advance in all disciplines of dentistry in order to provide our patients with the most predictable treatment regimens possible, understanding the greatest variable that stands in our way is the human variable. Elevating the standards of endodontic care is inexorably tied to an important dynamic in our armamentaria.

The objective of endodontic treatment has continued to be a constant since root canal treatment was first performed; the prevention and/or treatment of apical periodontitis such that there is complete healing and an absence of infection, while the overall long-term goal is the placement of a definitive, clinically successful restoration and preservation of the tooth. After all, the main objective in dentistry is to retain what nature has created!

Dental imaging has made leaps and bounds with the advent and use of the cone beam computed tomography (CBCT). Limited field of view images taken preoperatively will allow a three-dimensional rendering of the tooth to be treated. In essence, this will provide the practitioner with a more precise ‘road map’ with respect to the anatomic makeup of the tooth to be treated. CBCT has enlightened us to the complexity of the root canal system and thereby obliges us to 3D disinfection and obturation.

High magnification in the form of the dental operating microscope and the development of ultrasonics for conventional endodontics have enabled many practitioners to treat complex root canal anatomic variations more thoroughly and to tip the balance of healing in our favour.

The future of endodontics is bright as we continue to develop new techniques and technologies that will allow us to perform endodontic treatment painlessly and predictably, and continue to satisfy the underlying objective of tooth retention. In order to achieve and enjoy the successes that technologies allow us to have, we must get back to fundamentals and provide grass roots education in a step wise systematic manner to those that will be providing the treatment.

Peter Nkansah, DDS, Dip. Anaes.
Happy Birthday Canada! In the field of anaesthesia (for dentistry), the most significant development in the last 150 years was the introduction of local anaesthesia. In September, 1884, when Canada was still a growing teenager (7 provinces, 4 districts, and the Northwest Territories), an interesting presentation was made in Heidelberg, Germany. At the Heidelberg Ophthalmological Society’s annual meeting, the results of some experiments by a young ophthalmic surgeon (and the future father of local anaesthesia) named Karl Koller were presented. Cocaine, according to Koller’s friend and medical school classmate, Sigmund Freud, was a “miracle drug” capable of many things, including numbing whatever tissue it touched. The presentation of Koller’s results included a live demonstration of a painless procedure. In that audience sat Henry Noyes, who sent word of this advance home to New York City, where his account appeared in the New York Medical Record on October 11, 1884. Word of this incredible advance made it to the attention of William S. Halstead, the future father of modern surgery. Together with Dr. Richard J. Hall, they experimented on “sensory cutaneous nerves”. A letter titled “Hydrochlorate of Cocaine”, dated November 26, 1884 was written to the New York Medical Journal by Hall. In this letter, the numbing (and other) effects of injected 4% cocaine solutions were described for what would now be called the infraorbital and inferior alveolar nerve blocks for dentistry, and the ulnar nerve block for medicine. This letter was published on December 6, 1884. These dental blocks remain virtually unchanged today, making them one of the most important and interesting developments in dentistry over the last 150 years.

Mark Lin, BSc, DDS, MSc (Prostho), FRCD(C)
Without a doubt, dental implants as a viable tooth replacement therapy has dramatically impacted our dental profession and improved the quality of life for our patients. Compared to conventional prosthodontic tooth replacement treatments such as crowns, bridges, removable partial or full dentures, dental implants can provide improved biomechanical bone stimulation. Specifically, the concept of “Teeth In A Day” ( All On Four from Nobel Biocare, Pro Arch from Struamann, All In 1 Arch from Implant Direct, Teeth Express from Biohorizon, etc…) has dramatically enhanced the application of dental implants to benefit our patients. We can provide same day extractions of non-restorable teeth, immediately place the multiple dental implants and provide same day full arch screw retained fixed provisional prosthesis. The final full arch implant retained fixed prosthesis can replace and restore the daily functional and aesthetic demands to improve the quality of life for our patients.

David Farkouh, BSc, DMD, MSc (Paedo), FRCD(C)
In the last 150 years there have been many advancements in the profession of dentistry. The invention of dental implants for instance has revolutionized the treatment of edentulism, giving patients hope for lost teeth. However I feel that the greatest advancement in dentistry has been in the approach we take in treating our patient’s. Dentists now treat with more empathy and care for their patients overall well-being. In treating our patients in 2017 with this approach, our profession has become more humane. As a result, more of our patients are happy coming to our dental offices. Patient-centred care puts our patients in control of their own health, with our professional guidance. This gives them ownership of their dental health. This approach focuses on not only improving patient dental health but also improving their overall health. We are a much kinder profession today.

Fay Goldstep, DDS, FACD, FADFE
There have been countless significant technologies, treatments and products that have impacted on the practice of dentistry during the past 150 years. Today’s patient experience is far removed from the patient experience of the past. The office environment is pleasant, the diagnostic procedures are comprehensive and the treatment provides the patient with improved health, function, and esthetics. All of this with a minimum of pain and trauma!

For me the most significant change of all has been in our approach to treatment. Dentistry has reconnected with its medical roots. We treat our patients comprehensively, with much more understanding of the etiology of their conditions—dental, periodontal and systemic. We have reconnected the oral with the systemic. How did they ever separate? Seeing the whole picture gives us the ability to treat proactively and monitor the effects in all phases of treatment. The patient is the big winner!

George Freedman, DDS, FAACD, FIADFE
The two most significant developments: the advent of high-speed handpieces and the development of dental adhesion. The introduction of high-speed turbines in the 1960s made practitioners far more productive, and appointments shorter and more comfortable for patients. These instruments made dentistry affordable and accessible to the average patient, and stimulated the rise of dental insurance, helping many to obtain basic dental services. Comprehensive treatment for one or more teeth at a single appointment was now a practical reality. The development of adhesive dentistry in the 1950s, the actual bonding of restorative materials to tooth surfaces (as opposed to merely obturating prepared cavities), brought dentistry into the 20th century, positioning it for the future. Today, the concept of adhering restorations is universally accepted; interfacial breakdown is minimized, restorative materials support and strengthen existing tooth structures, and the transition from tooth to restoration is seamless. It is interesting to note that dentistry has built an extraordinarily bright future for both patients and the profession on the solid foundations of knowledge and experience, adapted over time to developments in science and innovations in technology.

Bruce Pynn, MSc, DDS
There have been numerous advances in Oral and Maxillofacial Surgery over the past 150 years which have benefited both the patient and the surgeon. It is difficult to pinpoint the single most significant development in oral and maxillofacial surgery. I consulted two experts in our specialty, Dr. Simon Weinberg, (Toronto, ON) and Dr. Daniel Laskin, (Richmond,VA) with a combined oral surgery experience of more than 100 years. We came up with a list!

Ambulatory anesthesia has greatly advanced patient care. Modern anesthesia monitoring, such as pulse oximetry and safer drugs regimes has allowed for millions of surgical cases to be performed in the office outside a hospital setting. The evolution of dental implants, with or without bone grafting, has transformed the reconstruction of the jaws. The developments in instrumentation such as high speed handpieces, mirco-saws, and rigid fixation have greatly enhanced the surgical techniques. The technological advances in radiology has made the panorex and digital radiography an integral part of every surgeon’s armamentarium.

These are but a few of the many advances within the specialty. It is very interesting to ponder and reflect on the past, present and future of our specialty.

Peter Birek, DDS, MSc, Dip. Perio
As we celebrate Canada’s 150th birthday, we have been asked to reflect on the most significant developments in dentistry since our country came into being. Since I have not been around that long, I will point out two notable non-dental advancements which, when finally spilled over to dentistry, had a profound impact.

The power of digital imaging that allowed ease of capture, efficient management, smart sorting, retrieving, storing, and ease of sharing of images. When the power spilled over to dentistry (i.e. when the use of clinical digital imaging came into main stream), it had a profound impact on the way we learn from our educators, from each other, from our peers, and from the critical review of our own cases.

The power of search engines that allow us to access pertinent information almost instantaneously – sort of a “just-in-time delivery” that revolutionized several industries. Instead of memorizing giga-brain-bites of data, clinicians can free their brains to think critically, at greater depth, and out-of-the-box, based on ever-evolving knowledge.

According to people in the know, “we ain’t seen nothing yet,” as we are very early in our journey. Just like Canada, we are young and evolving at 150. Happy Canada Day!

Janice Goodman, DDS
So much has changed in science, materials, techniques, knowledge and pain control that it would be hard to choose a single innovation that is THE most important or revolutionary. I feel that the most significant development in dentistry, is as much about philosophy as science. Dentistry is becoming more holistic and dentists are starting to act like dental physicians (a term coined by Dr. Al Fonder). We appreciate that the 5th cranial nerve integrates most of the input and output from the brain and that proprioception, highly innervated by oral tissues,is going to be one of the big buzz words in the future. Instead of focusing on extracting painful teeth as the barber did 150 years ago, we now focus on the health and well being of the person. According to a Harvard study (33,000 participants), the loss of 10 or more teeth was THE highest morbidity risk factor. We are learning to integrate newer ideas about tongue (myofunctional) function, airway, epigenetics, neurology, immunology, microbiology and more, to improve and extend lives. We are starting to work together and share ideas not just with medicine, but all sorts of fields with common interests. We can only dream of what our profession will look like in another 150 years. Good luck to those who will take up the baton!

Mark Nicolucci, DDS, MS, FRCD(C)
I believe the most significant development in dentistry over the past 150 years has to be the use of local anesthetic. Dentistry was certainly in a different place when the primary treatment choice was extraction, which typically involved significant pain. The ability to painlessly extract teeth, drill root canals, and restore teeth has changed dentistry and made it more accessible to the general population. As a result, oral health care has dramatically improved. Within my own journal topic of implantology, the most significant development, besides the advent of the implant itself, would likely be the applicability of implants. Initially implants were only for edentulous patients and had to be placed in a sterile hospital setting. Today it is rare I’ll meet a patient who is not a good candidate for implant placement which can often be placed simply, in under an hour. The number of people that can now benefit from predictable long-term tooth replacement is enormous and, as with local anesthetic, this has produced a dramatic improvement in the oral health care we provide.

James Posluns, DDS, D. Ortho; Randy Lang, DDS, D. Ortho
In orthodontics, three advances distance themselves from the rest. In 1970, Dr. Larry Andrews developed the first preadjusted orthodontic appliance, significantly reducing the complexity of orthodontic wire bending by incorporating a prescription into the bracket that automatically tipped, torqued and positioned teeth upon insertion of a standard edgewise archwire. By the mid-70’s, the preadjusted bracket was combined with acid etch enamel bonding, effectively eliminating the need for bands. Shortly thereafter, the modern, preadjusted bonded bracket became the mainstay of orthodontics worldwide.

The development of nickel titanium archwires arguably changed orthodontics overnight. These highly flexible archwires permit the simple application of the light, continuous, long-acting forces critical for predictable tooth alignment. Nickel titanium freed the orthodontist from the laborious task of bending multiple loops into stainless steel archwires permitting efficient delegation in orthodontic practice to become the new reality.

Clear plastic aligners, and the three dimensional virtual technology that supports their fabrication, have revolutionized orthodontics forever. Aligners effectively move teeth in all dimensions without the need for conventional brackets and wires. Clear aligners have made esthetic orthodontic treatment mainstream, and has blazed a trail into direct consumer marketing. Since the first computer-generated aligner was developed in 1997, aligners have grown into a multi-billion dollar international industry.