How dentistry is changing

Is dental caries still the main problem of children and adults in Poland and Europe?
Ewa Czochrowska, MD, PhD:  Unfortunately, dental caries is still a big problem in our country. According to epidemiological studies, 57 percent of three-year-olds, 80 percent of five-year-olds and 90 percent of seven-year-olds in our country have teeth affected by caries. Statistically, a five-year-old child has 5 diseased teeth. However, it is important to note that dentists, especially pediatric dentists, are now focusing heavily on prevention. They teach proper hygiene, work to change eating habits in their patients. The effects of preventive measures can already be seen in Scandinavian countries. There, caries disease is practically a thing of the past, and more and more people retain their natural teeth for life. Consequently, in Scandinavia, for example, we are seeing a shift in the types of dental interventions. From treating the consequences of carious disease - towards treating developmental anomalies, both within the teeth themselves and the entire stomatognathic system, including malocclusion or age-related changes.
 
And what has changed in dentistry over the past several years?
E.C.: Interdisciplinary collaboration, in the broadest sense, has improved significantly. I mean not only cooperation between specialists in different fields of dentistry, but also within the dental team itself. For many years it has included a dental hygienist and a dental technician. Their education in the form of full-time undergraduate studies has been conducted at the MUW for many years, and a few years ago the Department of Oral Hygiene was established within the Faculty of Dental Medicine. Today, dentists are also increasingly cooperating with specialists in other fields. Orthodontists cooperate with pediatricians, ENT specialists and rheumatologists. With physiotherapists for temporomandibular joint rehabilitation and with speech therapists for tongue dysfunction and speech disorders. It is also not uncommon for us to consult with psychologists in the treatment of congenital craniofacial or severe skeletal defects and for planned orthognathic surgery. When treating patients with congenital craniofacial defects, we also need to consult a geneticist. On the other hand, we cooperate with oncologists or cardiologists with regard to the treatment of mucosal and periodontal diseases.

And when it comes to the patient - is their role in the treatment process greater now?
E.C.: The relationship between the doctor and the patient is clearly changing. From a paternalistic relationship it becomes a parallel system, that is, one in which the patient participates in the decision-making process. Of course, not in every area of dentistry can patient participation in treatment planning be the same. In orthodontics, where aspects of facial or smile aesthetics play an important role, we always consider what the patient's priority is. Of course, it is important to remember that abnormal occlusion can contribute to the faster development of tooth decay or increased tooth wear, as well as cause speech problems or disorders of the temporomandibular joint. However, I emphasize that patient satisfaction is very important in orthodontic treatment. Psychological research shows that patients are satisfied with their treatment when their expectations regarding the course of the treatment and its outcome in relation to the final outcome and final results are consistent. It's not that everyone expects a Hollywood smile and we can always get it. But it is about us agreeing on a treatment plan with the patient and informing them of its limitations, as well as complications in the course of treatment. Achieving a Hollywood smile often requires additional prosthetic treatment and changes in the shape and color of teeth, which is not always interesting for the patient or significantly increases the cost of the treatment. But improving the alignment of natural teeth, such as correcting pathological tooth migration in the course of periodontitis, will be very satisfying to the patient and will "aid" periodontal treatment. Also it will allow to keep natural teeth longer.
 
3D imaging is increasingly being used in medicine. Is this technology also present in dentistry?
E.C.: Certainly, the introduction of three-dimensional imaging techniques is very important in both teaching and diagnostics, and widely used in dental treatment. For example, in teaching we use a device called simodont. It allows to perform a simulated dental procedure on a computer screen. We have a high-resolution display that shows objects in 3D, and the practitioner works with 3D glasses.
When it comes to diagnostics, 3D imaging is used primarily in radiology. In orthodontics, three-dimensional images are used, for example, to diagnose impacted teeth. This allows us to very precisely locate the tooth, and also to check its relationship to adjacent teeth. We then manage to accurately predict if we even have a chance of bringing such a tooth into the dental arch. For several years we have been using scanning diagnostic models or direct scanning of the patient's teeth in the mouth instead of traditional impressions in prosthodontics or orthodontics. Such tooth scans are used in orthodontic diagnosis or, for example, in planning orthognathic treatment of skeletal malocclusion. Using special computer programs, a three-dimensional x-ray can be superimposed over a scan of the teeth and the maxilla or mandible can be accurately planned to displace during surgery, or necessary tooth displacement can be planned before surgery. This is undoubtedly a revolution and advancement in dental treatment, especially for severe craniofacial defects like clefts or other malformations.
I have also mentioned treatment. Here, 3D technology is often used to print prosthetic restorations, bite splints or surgical templates. These surgical templates are very helpful when placing dental implants or orthodontic micro-screws on the palate. Orthodontic microscrews are excellent tools for achieving tooth displacements that were not possible in the past and are now commonly used in orthodontics. The difference between a dental implant, which replaces a lost tooth, and an orthodontic micro-screw, which is used in orthodontic treatment, is that the micro-screw does not permanently integrate with the alveolar bone and can be easily "unscrewed" at the end of the treatment. Planning implant treatment using 3D imaging techniques allows for very precise selection of the shape, size of the implant and the angle of insertion, which significantly increases the predictability of treatment.
Also recently, transparent trays (aligners) have been introduced in orthodontics to treat malocclusion. They are practically invisible on the teeth. Based on 3D scans of the teeth, the orthodontic treatment is planned and simulated. Then, using also 3D technology, a few, sometimes a dozen or so trays are printed, which the patient has to change in specific time intervals, usually every 7-14 days.

What about artificial intelligence? Will robots treat our teeth in the future?
E.C.: Artificial intelligence will help us in both diagnosis and treatment. Anyway, this is already happening. In orthodontics, artificial intelligence is being used in cephalometric analysis where points are determined on a lateral telerentgenogram of the skull to define the position of the maxilla, mandible, or incisal teeth. Also, artificial intelligence is used in monitoring the progress of orthodontic treatment or teeth cleaning. However, the use of artificial intelligence comes with the risk that the control of the course of treatment is outside the supervision of the doctor. We are already seeing this with overlay treatment (aligners). There are many companies that advertise this type of treatment directly to patients and offer to scan teeth and issue overlays often even without a dentist’s involvement. Orthodontic treatment should be carefully planned, monitored, and retention treatment should also be planned and supervised to ensure malocclusion does not recur over time. Therefore, the complete replacement of a doctor, including a specialist in orthodontics, with artificial intelligence is not possible, but certainly AI can significantly assist our work.
 
Sometimes malocclusion or other dental problems significantly deform facial features - is it possible to restore its proper proportions? 
E.C.: Facial aesthetic disorders most often occur when a patient has a misaligned jaw or mandible. In some cases, we may use braces - this method works well, for example, for children who have a mandible that is too far back (it is too small). In this case we use braces to stimulate the growth of the mandible. However, in adults who have skeletal defects, we must resort to orthognathic surgery to restore proper facial proportions and symmetry. We then cooperate with an oral and maxillofacial surgeon to determine jaw and mandibular misalignments that will help achieve the ideal face. But note: "ideal" here means symmetrical and proportionate - not necessarily beautiful. The previously mentioned 3 D techniques and computer programs are very useful in planning this type of treatment. They allow us to do a simulation and show the patient what their face will look like after the procedure. It is a very good communication tool. The patient has a better understanding of what the outcome will be after treatment and decides whether they accept it or not.

You deal with autotransplantation of teeth - what is this procedure and when can it be performed?
E.C.: It involves the extraction of a tooth from one site, to be implanted into another. My first exposure to autotransplantation of teeth was at the University of Oslo in Norway, where I went for training. In Scandinavia it's a routine procedure. Norwegians have performed it in Oslo since the late 1950s. I really wanted to apply this method of treatment to patients in Poland. And it worked. For 22 years together with Pawel Plakwicz, MD, PhD, from the Department of Periodontology and Oral Medicine, we have been dealing with autotransplantation of teeth with incomplete root development.  
This procedure is mainly performed in children and adolescents. The most important indication to have it done is when the child has lost its front tooth or teeth, i.e. there was a complete tooth dislocation (commonly speaking - the tooth fell out). This is when we usually use premolar transplantation - that is, we take that tooth and implant it in place of the missing central incisor. Of course, after transplantation, the shape of the premolar, for example, is changed with composite materials to the shape of the front tooth. It is worth reminding here that implants cannot be used in children and adolescents. In case of incisor tooth loss in the jaw, the remaining options are a removable denture (which is not a very attractive solution, especially for teenagers) or a premolar autotransplantation. The latter method has a very high success rate of over 90 percent. And what is very important, transplanted teeth behave naturally, that is, they grow with the child.
Autotransplantation can be used not only after complete tooth dislocation, but also in the case of congenital absence of the tooth bud. The procedure also works well for ectopically located teeth, i.e. teeth that have not erupted and are retained in the bone. The surgeon can take out such a tooth and place it correctly where it should be.
 
Let's look further into the future. What therapies that are now in research and experimentation are likely to become widespread?
E.C.: The future will be regenerative dentistry, that is the regeneration of teeth or their tissues or peri-dental tissues from stem cells. For now, such treatments are still in the laboratory research phase. But perhaps in a decade or so, even if a tooth cannot be cloned, scientists may be able to clone peri-tooth tissue, such as the periodontium. In the future, so-called bioprinting and inhibition of bacterial growth in the oral cavity and prevention of biofilm formation may also become widespread. The work is aimed at preventing the formation of plaque, as it is a pathogenic factor for both caries disease and periodontal diseases.

Interviewed by: Iwona Kołakowska
Photo: Michał Teperek
Communication and Promotion Office MUW