Who among us hasn’t had this thought, as a dentist industriously and cheerfully chisels and scrapes and drills away at your teeth: Surely there is a better way.
When anthropologists last month discovered evidence of dental handiwork in a 14,000-year-old tooth, the surprising thing about it wasn’t the fact that people in the Stone Age had cavities and tried to do something about them. It was the fact that the procedure seemed so… familiar.
“The earliest dental caries manipulation entails an adaptation of the toothpicking technique … to scratching/levering activities within the carious lesion using microlithic points,” the authors wrote in the journal Scientific Reports.
To be clear, dentistry has gone through many revolutions over the millennia. No one would accuse dentists of using microlithic points on our carious lesions today. The field is far safer, geared toward prevention, and less painful than even a few hundred years ago, in the crude day of tooth extractions by barber surgeons. Fluoride, anesthesia, and “drill 'n fill” dentistry have been remarkably successful at helping us keep our teeth healthy well into our old age. This chart, for example, shows how much the proliferation of fluoridated water has helped reduce dental problems.
But for all its progress, dentistry is still a part of medicine that feels weirdly locked in time. There you are, moving your tongue left and right as your own saliva pools in the back of your throat. A gloved finger pulls back your lip and a familiar armamentarium of drills and metal tools sparkles nearby.
Sitting in a dentist’s chair can feel a lot like time travel – always back to the same jaw-aching time. In the age of laser eye surgery, laparoscopic procedures for complex surgeries, gene therapy, and artificial wind pipes made on 3D printers, dentistry still tends to feel a lot like carpentry.
Dentists tend to be, understandably, quite defensive of the technological innovations in their field. Fluoride in drinking water, new composite materials for filling cavities so that dentists don’t have to drill as much, and dental implants are just a few of the transformations.
“There’s a lot of innovation,” said Denis Kinane, dean of the dental school at the University of Pennsylvania. To say otherwise would be dismissing revolutions. “You’d be denying the implants that have totally transformed everything.”
But are these revolutions, or evolutions of existing ideas? People began working on the implant concept in the early 20th century. So even if technology, science, and materials didn't catch up to make them practical and routine until the last couple decades, the idea doesn't exactly seem profound to most non-dentists. Where are the technologies we never dreamed of? Whither dentistry's killer app?
David Mooney is a Harvard University bioengineer who works on big problems in medicine. He's testing a vaccine against the deadly skin cancer melanoma and is developing a method to neuter pets without surgery. But more than a year ago, he and colleagues published a study about some early work in rats, showing that a low-power laser could be used to trigger existing dental stem cells to regenerate a portion of a tooth in rats. He hasn’t heard the end of it since.
“This one has been really striking to me. Literally, I get an inquiry still almost every day. Something about this really strikes a chord with a large number of people,” Mooney said. “It speaks a little bit to the fact that the options in general that are available today for restorative dentistry are probably the same options that have been available for quite a few years and people are very excited for a different approach -- a regenerative approach -- instead of a simple replacement.”
Mooney’s work hasn’t been tested in people yet, but there are eager volunteers trying to sign up. Praveen Arany, a dentist who headed up the project with Mooney, is moving to become a professor at the University of Buffalo this year and hopes to start the first clinical trials in a year.
“I think incremental increase in knowledge is more rewarded and accepted easily because it follows that line of thought -- it’s the next step,” Arany said. “Something like this steps out of the box. I think it’s disruptive.”
Asked what else has been similarly disruptive in dentistry, Arany mentioned plastic, tooth-colored fillings. Apparently, the dentistry world was pretty resistant to them and there were problems at first with them getting discolored, being too soft, and needing to be replaced. Metal fillings seemed like they would never be unseated as the dentist's only real option, Arany said. But the technology has become mature and now they're widely used. Patients benefit because dentists don't need to drill and excavate as much of the tooth as they would have in the past.
So is it just a public relations problem? Are dentists just terrible at communicating the advances in their field? Or is it us? Perhaps we just feel a little bit vulnerable about our mouths.
"You really have to wonder why the patients don’t have a greater sense" of the progress, said Jonathan Garlick, a professor of oral pathology at Tufts University School of Dental Medicine. "I think it’s still viewed as being an invasive procedure. Someone’s hands in your mouth is something that can make people uneasy."
And this is not just a modern-day squeamishness. A letter, published in 1845 in the New England Journal of Medicine, called out medical colleagues for not taking the mouth seriously enough.
“My object in this article is principally to call the attention of the profession to the subject of the teeth—a subject which has been too much neglected. What, indeed, can be the reason that more attention has not been paid by physicians to this branch of surgery, or that it should be viewed as of second or third rate importance, if regarded at all?” John Clough wrote in making an impassioned case for the progress of dental science. "If a man has lost his teeth entirely, he cannot enjoy so good health as though his teeth were perfect, nor can he expect to live so long."
So, we're at an impasse. Ask a dentist how the field has changed and you get a laundry list of innovations. But when you're sitting in that chair, watching a dentist's eyebrows knit and furrow as he passes silent judgment over your brushing and flossing, even a middle-aged person will feel exactly like a little kid again -- down to that familiar whirring noise in the background.
But Arany and others are moving ahead with new technologies. There's hope that people of the future won't feel like they're in the dental dark ages.
"You do make a good point, though. This kind of cleaning that means someone has got to spend time scraping every tooth is laborious and antiquated," Kinane said. "But we’re working on that right now."