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SPECIAL SUPPLEMENT TO
SEPTEMBER 2009
C O N T E N T S
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EDITOR
Michael Glick, DMD, professor of oral medicine,
Arizona School of Dentistry & Oral Health; associate
dean for oral-medical sciences, School of Osteopathic
Medicine in Arizona, A.T. Still University, Mesa
Laura A. Kosden
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James H. Berry
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tury, Willoughby Miller recognized the role of bacteria in caries and periodontal disease,3,4 but it
would be many years before his observations were
accepted and many more before oral disease prevention was practiced widely.
Many scientific advances have led to better oral
health and improved dental care since the founding
of the ADA. However, it is impossible to include in
this supplement all of the developments that
occurred during the 150-year period, including discoveries such as safe and effective pain control,
high-speed dental instrumentation, dental
implants, advances in the diagnosis and treatment
of oral cancer, and numerous advances in the
dental specialties. Instead, this supplement focuses
on selected topics, with an emphasis on developments in the last 50 to 60 years. These topics
include the following:
dthe evolution of oral health science in the
United States;
dthe role of basic science in transforming technology and dental practice;
dscientific advances in the biological understanding, prevention, diagnosis and treatment of
dental caries and periodontal disease.
This supplement also includes a view of the
exciting future that science likely will bring to dentistry and oral health care. It describes the evolution
of oral health science in the United States and the
transformative role of basic science in technology
and dental practice, because they transcend all areas
of dentistry. In addition, it includes discussion of scientific advances in dental caries and periodontal disease, because these diseases are responsible for the
vast majority of oral disease and tooth loss. Science
is an international endeavor, with no geopolitical
boundaries, and we recognize that investigators outside the United States have made many seminal discoveries and contributions to dentistry. However,
because this supplement specifically commemorates
the 150th anniversary of the ADA, the authors
emphasize contributions of scientists who lived and
worked in the United States.
In their review of the role of basic science in technology development and dentistry, Drs. Snead and
Slavkin7 discuss how science fuels the engine of
innovation and discovery. They provide three fascinating examples of dentists who transformed medicine in the last 50 to 60 years:
dNorman Simmons refined the techniques of isolating DNA, which Rosalind Franklin used to
create the first x-ray crystallography images from
DNA and which led James Watson, Francis Crick
and Maurice Wilkins to predict the structure of
DNA in 19538;
dRobert Ledley pioneered computerized tomographic scanning in the early 1950s,9,10 a remarkable achievement that led to modern diagnostic
imaging in both dentistry and medicine;
dRussell Ross and colleagues first proposed that
atherosclerosis is an inflammatory lesion caused by
localized injury to the lining of the arterial wall.11,12
Drs. Snead and Slavkin also discuss recent
breakthroughs in the digital revolution that have
given us the new field of bioinformatics and the
amazing capacity for diagnostic imaging. Genomics
and proteomics continue to progress at a rapid
pace, making it possible for researchers to determine the full complement of genes and proteins
that make us who we are. Personalized medicine
and dentistry are becoming a reality, enabling
clinicians to make diagnostic, prognostic and therapeutic decisions on the basis of a patients genetic
makeup and environmental exposures. Stem cell
Drs. Armitage and Robertson14 note that most significant scientific advances in periodontology have
come about as a result of the collective efforts of
visionary pioneers and through multidisciplinary
collaborations between scientists, clinicians, organized dentistry, academia, industry and government. Relatively recent advances in periodontology
have changed fundamentally how clinicians detect
JADA, Vol. 140
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CONCLUSION
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Many thanks are due to the authors and anonymous peer reviewers of
the articles in this supplement and to the staff of The Journal of the
American Dental Association, the ADA Department of Library Services,
the Paffenbarger Research Center and the National Institute of Dental
and Craniofacial Research. All unselfishly shared their time and expertise to make this supplement possible.
The financial support of the sponsors that made this supplement a
reality is gratefully acknowledged.
1. Dammann G, Bollet AJ. Images of Civil War Medicine: A Photographic History. New York City: Demos Medical Publishing; 2008:41-42.
2. 125th anniversary commemoration. 1859-1880: the early years.
American Dental Association JADA 1984;108(4):483.
3. Miller WD. Original Investigations Concerning Pyorrhea Alveolaris:
The Micro-Organisms of the Human Mouth. Philadelphia: The S.S. White
Dental Mfg. Co.; 1890.
4. Miller W. The presence of bacterial plaques on the surface of teeth
and their significance. Dent Cosmos 1902;44:425.
5. Gutmann JL. The evolution of Americas scientific advancements in
dentistry in the past 150 years. JADA 2009;140(9 suppl):8S-15S.
6. Gies WJ. Dental Education in the United States and Canada: A
Report to the Carnegie Foundation for the Advancement of Teaching.
New York City: The Carnegie Foundation for the Advancement of
Teaching; 1926.
7. Snead ML, Slavkin HC. Science is the fuel for the engine of technology and clinical practice. JADA 2009;140(9 suppl):17S-24S.
8. Wilkins MHF. The molecular configuration of nucleic acids. Nobel
Lecture, December 11, 1962. http://cmbi.bjmu.edu.cn/news/report/2003/
DNA50/source/wilkinslecture.pdf. Accessed July 17, 2009.
9. Ledley RS, Ayers WR. Computerized medical imaging and graphics
evolves from computerized tomography. Comput Med Imaging Graph
1988;12(1):v-xviii.
10. Ledley RS. Innovation and creativeness in scientific research: my
experiences in developing computerized axial tomography. Comput Biol
Med 1974;4(2):133-136.
11. Ross R, Glomset JA. Atherosclerosis and the arterial smooth muscle
cell: proliferation of smooth muscle is a key event in the genesis of the
lesions of atherosclerosis. Science 1973;180(93):1332-1339.
12. Ross R. The pathogenesis of atherosclerosis: a perspective for the
1990s. Nature 1993;362(6423):801-809.
13. Zero DT, Fontana M, Martinez-Mier EA, et al. The biology, prevention, diagnosis and treatment of dental caries: scientific advances in the
United States. JADA 2009;140(9 suppl):25S-34S.
14. Armitage GC, Robertson PB. The biology, prevention, diagnosis and
treatment of periodontal diseases: scientific advances in the United
States. JADA 2009;140(9 suppl):36S-43S.
15. Garcia I, Tabak LA. A view of the future: dentistry and oral health
in America. JADA 2009;140(9 suppl):44S-48S.
16. American Dental Association. Future of Dentistry. Chicago:
American Dental Association, Health Policy Resources Center; 2001.
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AB STRACT
Background. During the last 150 years,
dentistry in the United States faced many challenges as it developed its scientific foundation.
In the latter part of the 19th century, clinical
practice was driven by empirical evidence, and
the first few decades of the 20th century set
the stage for Americas scientific evolution of
dentistry.
Conclusions. Seminal developments in
Americas contribution to science in dentistry
and oral health included the 1926 Carnegie
Foundation for the Advancement of Teaching
report and the vision of William J. Gies; the
development of scientific dental journals; the
role of immigrant dental scientists from Europe
and oral biology as a discipline; and the establishment of the National Institute of Dental
Research in 1948.
Clinical Implications. Due in large part
to Americas contribution to dental science and
practice, we are at the brink of a transformation that may expand the role of the dental
profession dramatically and improve the oral
health of people throughout the world.
Key Words. Dental science; dental practice;
history of dental science.
JADA 2009;140(9 suppl):8S-15S.
and oral pathology.4,5 Even in light of these developments, however, skeptics such as Alton Howard
Thompson from Topeka, Kan., challenged the empirical basis of dentistry as it was practiced in the
19th century.6
Willoughby D. Miller, who received his Doctor of
Dental Surgery degree from the University of Pennsylvania, Philadelphia, in 1879, was one of the first
true American dental scientists. His seminal 1890
publication, The Micro-Organisms of the Human
Mouth: The Local and General Diseases Which Are
Caused by Them, 7 reported that when carbohydrates are mixed with saliva and incubated at 37C,
they generated lactic acid that could decalcify an
entire tooth crown. He also identified
several bacteria that created acids
during their metabolism, presented
various proposals regarding the role of
bacteria in oral disease and proposed
that saliva could be used for research.
Perhaps most importantly, he
attempted to reorient the dental profession from focusing on treatment to
focusing on disease prevention.
Although many people were at the
forefront of dentistry as an evolving
science in the United States, the following deserve special mention: G.V.
Black, Truman Brophy, Edmund
Dr. William J. Gies
Noyes, Charles N. Johnson, Thomas
Gilmer, W.G. Skillen, Edgar D. Coolidge, Balint
Orban, Frederick B. Moorehead, Edward H. Hatton
and S.D. Tylman. Many of these people were associated with schools in the Chicago area, including
the Chicago College of Dental Surgery at Loyola
University; Northwestern University Dental School;
and the University of Illinois, College of Dentistry.
The development of science that would define the
essence of dentistry as a whole, beyond that of a
technical or empirical profession, had its roots in the
late 1800s and early 1900s, and major benchmarks
that affected contemporary dentistry in the third to
the fifth decades of the 20th century were set. Before
the late 1800s and early 1900s, dentistry in the
United States was recognized throughout the
Western world for its technical excellence, but it was
not recognized generally as having a scientific basis.
THE CARNEGIE FOUNDATION FOR THE
ADVANCEMENT OF TEACHING REPORT
AND THE VISION OF WILLIAM J. GIES
In 1926, the Carnegie Foundation for the Advancement of Teaching published a report by William J.
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establish a research endeavor in an academic environment.9 Gottlieb moved to the United States in
1940. He was associated briefly with Columbia University and the University of Michigan, Ann Arbor,
before moving to Baylor University, Dallas, where
he was a professor and the chair of the Department
of Pathology and Research in the School of Dentistry
until his death in 1950.10,11 During his career, Gottlieb wrote numerous scientific articles and four
textbooks and is responsible for founding the study
of oral histology. He has been acknowledged as
being the first dentist to integrate basic science
information with clinical treatment.12
Balint Orban, a protg of Bernhard Gottlieb,
came to the United States from Vienna in 1927 to
establish a research program at the Chicago College
of Dental Surgery at Loyola University. He later
joined the faculty at the University of Illinois College of Dentistry, Chicago. Rudolf Kronfeld was
another protg of Bernhard Gottlieb. His short
career at Loyola University was marked by many
research advancements that helped place science
into the practice of dentistry. His message to clinical
dentists was expressed in an article in which he
delineated the crucial connection between the techniques of restorative dentistry and the biological
foundation on which those techniques rested.13 In
1939, one month before he was to become president
of IADR, Kronfeld died, as his colleague Edgar D.
Coolidge put it, surrounded by his library, his histological material and his work in progress for the
coming season.14
Harry D. Sicher began his career in the United
States at the Chicago Medical College, and then he
moved to the Chicago College of Dental Surgery at
Loyola University. Joseph Peter Weinmann began
his U.S. career in 1938 at the University of Illinois
College of Dentistry, followed by one year at
Columbia University. He then joined the faculty at
the Chicago College of Dental Surgery at Loyola
University. In 1946, he returned to the University of
Illinois. Both scientists undertook significant
research endeavors in oral anatomy, histology, bone
physiology and oral pathology; Weinmann received
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TABLE
DATES
SIGNIFICANT FOCUS/ACCOMPLISHMENTS
H. Trendley Dean
1948-1953
Provided first leadership for dental research at the National Institutes of Health (NIH)
(1931); appointed director of Dental Research Section (1945); became first director of the
National Institute of Dental Research (NIDR) (1948); provided for oversight by the National
Advisory Dental Research Council; awarded first extramural dental research grants and fellowships; supported research on mottled enamel and fluoride, fluorosis, prevention of
dental caries by fluoride and water fluoridation; established intramural research units for
basic and clinical science, created an intramural section for epidemiology and biometry;
advocated for integration of dental health into mainstream medical research.
1953-1966
With H. Trendley Dean, led Grand Rapids, Mich., fluoridation study that established water
fluoridation as a safe, effective and economical way to prevent dental caries; established
the first Board of Scientific Counselors to provide advice to the director for intramural
research program; established intramural Laboratory of Biochemistry; provided oversight
for intramural building and laboratory facilities of intramural research program; encouraged dental faculty in the United States to apply for research grants; expanded NIDR
research to dental materials, human genetics and oral medicine; funded first multidisciplinary cleft palate study.
Seymour J. Kreshover
1966-1975
Previously served as the scientific director of the NIDRs intramural research program;
enhanced grants in the neurosciences, pain research, caries prevention through the
National Caries Program (a merger of both intramural and extramural programs) and
craniofacial research and cleft palate reconstruction; enabled the formation of the intramural Laboratory of Oral Medicine, the Laboratory of Microbiology, and expanded
research investments in periodontal diseases, autoimmune diseases and allergic disorders;
expanded intramural research and grants to include pain research and anesthesiology, as
well as the behavioral sciences.
David B. Scott
1976-1981
Harald Le
1983-1994
Established the Epidemiology and Oral Disease Prevention Program to include periodontal
and other diseases of the oral cavity; established the Dentist Scientist Award program to
enhance clinical research; expanded extramural dental research to include research centers
in the collective fields of oral biology, oral and craniofacial diseases and disorders, and
minority oral health; initiated first national surveys of U.S. adult oral health and childrens
caries; initiated programs of continuing dental education and public information to translate research findings; established World Health Organization Collaborating Center for
Dental Research and Training.
Harold C. Slavkin
1995-2000
2000-present
Increased support for research on oral health disparities, neuroscience of chronic pain,
head and neck cancer, Phase III clinical trials, genomics (including genome-wide association studies), systems biology of salivary glands and diagnostic potential of saliva; supported creation of a dental practice-based research network and a formal Dentist Scientist
Training Program for concomitant Doctor of Dental Surgery/Doctor of Philosophy degree
training; fostered interdisciplinary research as cochair of the NIH Roadmap program on
Research Teams of the Future; helped lead NIH initiative to enhance peer review; served as
acting deputy director of NIH (November 2008-spring 2009).
Lawrence A. Tabak
Palmolive Company, New York City) and the proceedings were published in JDR.17 The journal
Archives of Oral Biology began publication the same
year. In 1988, the first step was taken to form a
society of oral biologists as part of a section of the
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In the last 150 years, dentistry has faced many challenges as it has moved from a purely technical profession to one that is increasingly science-based. The
future must be driven by a global vision for the provision of science-driven oral health care and the commitment of dental educators and practitioners to embrace science as an integral part of our profession.
Disclosure. Dr. Gutmann did not report any relevant disclosures.
1. Gies WJ. Dental Education in the United States and Canada: A Report
to the Carnegie Foundation for the Advancement of Teaching. New York
City: The Carnegie Foundation for the Advancement of Teaching; 1926.
2. Lesky E. The Vienna Medical School of the 19th Century. Baltimore:
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3. Lufkin AW. A History of Dentistry. Philadelphia: Lea & Febiger; 1938.
4. International Association for Dental Research. The First Fifty-Year
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728-737.
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ABSTRACT
Background. The biological, chemical, behavioral and physical sciences provide the fuel for innovation, discovery and technology that continuously improves the quality of the human condition. Computer power
derived from the dramatic breakthroughs of the digital revolution has
made extraordinary computational capacity available for diagnostic
imaging, bioinformatics (the science of information) and numerous
aspects of how we practice dentistry in the 21st century.
Overview. The biological revolution was initiated by the identification
of the structure for DNA in 1953, a discovery that continues to catalyze
improvements in patient care through new and better diagnostics, treatments and biomaterials. Humanitys most basic and recognizable characteristicsincluding the faceare now better understood through the elucidation of our genome and proteome, the genes and proteins they encode.
Health care providers are beginning to use personalized medicine that
is based on a persons genetic makeup and predispositions to disease
development.
Conclusions. Advances in the fields of genetics, developmental and
stem cell biology, and many other disciplines continue to fuel innovative
research findings that form the basis for new diagnostic tests, therapeutic
interventions and procedures that improve the quality of life for patients.
Scientists are on the threshold of applying knowledge in stem cell biology
to regenerative medicine and dentistry, heralding an era when clinicians
can consider using biological engineering to replace tissues and organs
lost to disease or trauma.
Key Words. Discovery; molecular biology; chairside application.
JADA 2009;140(9 suppl):17S-24S.
Dr. Snead is a professor, Center for Craniofacial Molecular Biology, School of Dentistry, The University
of Southern California, 2250 Alcazar St., Los Angeles, Calif. 90033, e-mail mlsnead@usc.edu.
Address reprint requests to Dr. Snead.
Dr. Slavkin is a professor, Center for Craniofacial Molecular Biology, School of Dentistry, The University
of Southern California, Los Angeles.
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ABBREVIATION KEY. BMP: Bone morphogenetic protein. NIDCR: National Institute of Dental and Craniofacial Research. 3-D: Three-dimensional. UCLA: University
of California, Los Angeles.
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Dr. Robert Ledley. Courtesy of National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md.
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an inflammatory disease. These contributions are
examples of how scientific advances in improving
the human condition were derived from the passion
and creativity of people who began their careers in
dentistry.
TISSUE-DESTRUCTIVE ENZYMES
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71. Ellison SA, Mashimo PA, Mandel ID. Immunochemical studies of
human saliva, I: the demonstration of serum proteins in whole and
parotid saliva. J Dent Res 1960;39:892-898.
72. Mandel ID. The diagnostic uses of saliva. J Oral Pathol Med 1990;
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73. Madonia JV, Bahn AN, Calandra JC. Salivary excretion of Coxsackie
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74. Oppenheim FG, Xu T, McMillian FM, et al. Histatins, a novel family
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75. Schlesinger DH, Hay DI. Complete covalent structure of statherin, a
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76. VanDyke TE, Levine MJ, Herzberg MC, Ellison SA, Hay DI. Isolation of a low molecular weight glycoprotein inhibitor of calcium phosphate
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77. Kauffman DL, Bennick A, Blum M, Keller PJ. Basic proline-rich proteins from human parotid saliva: relationships of the covalent structures
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78. Wong RS, Hofmann T, Bennick A. The complete primary structure of
a proline-rich phosphoprotein from human saliva. J Biol Chem 1979;
254(11):4800-4808.
79. Scannapieco FA. Salivary biochemistry in Buffalo: the legacy of
Michael J. Levine. J Dent Res 2003;82(2):76-81.
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response to oral administration of glucosyltransferase antigen complex.
Infect Immun 1980;28(2):441-450.
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1-8.
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89. U.S. Department of Health and Human Services. Oral Health in
America: A Report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, National Institutes of Health,
National Institute of Dental and Craniofacial Research; 2000. NIH publication 00-4713.
ABSTRACT
Background. Scientific advances in cariology in the past 150 years
have led to the understanding that dental caries is a chronic, dietomicrobial, site-specific disease caused by a shift from protective factors favoring
tooth remineralization to destructive factors leading to demineralization.
Epidemiologic data indicate that caries has changed in the last century; it
now is distributed unequally in the U.S. population. People who are
minorities, homeless, migrants, children with disabilities and of lower
socioeconomic status suffer from the highest prevalence and severity of
dental caries.
Results. Scientific advances have led to improvements in the prevention, diagnosis and treatment of dental caries, but there is a need for new
diagnostic tools and treatment methods.
Conclusions and Clinical Implications. Future management of
dental caries requires early detection and risk assessment if the profession is to achieve timely and cost-effective prevention and treatment for
those who need it most. Dental professionals look forward to the day
when people of all ages and backgrounds view dental caries as a disease
of the past.
Key Words. Caries; remineralization; saliva.
JADA 2009;140(9 suppl):25S-34S.
Dr. Zero is the associate dean for research, a professor and the chair, Department of Preventive and
Community Dentistry, and the director, Oral Health Research Institute, Indiana University School of
Dentistry, 415 Lansing St., Indianapolis, Ind. 46202-2876, e-mail dzero@iupui.edu. Address reprint
requests to Dr. Zero.
Dr. Fontana is an associate professor and the director, predoctoral education, Department of Preventive
and Community Dentistry, School of Dentistry, and the director, Microbial Caries Facility, Oral Health
Research Institute, Indiana University School of Dentistry, Indianapolis.
Dr. Martnez-Mier is an associate professor and the director, the Fluoride Research Program, Department of Preventive and Community Dentistry, Indiana University School of Dentistry, Indianapolis.
Dr. Ferreira-Zandon is an associate professor and the director, Early Caries Detection Program, Department of Preventive and Community Dentistry, Indiana University School of Dentistry, Indianapolis.
Dr. Ando is an assistant professor, Department of Preventive and Community Dentistry, Indiana University School of Dentistry, Indianapolis.
Dr. Gonzlez-Cabezas is an associate professor and the director, Secondary Caries Program; director,
Graduate Education, Department of Preventive and Community Dentistry; and director, Laboratory
Research Facility, Oral Health Research Institute, Indiana University School of Dentistry, Indianapolis.
Dr. Bayne is a professor and the chair, Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor.
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people.42,43 Much remains unknown about geneticenvironmental relationships in caries etiology and
risk assessment, but the future holds interesting
possibilities for improvements in caries diagnosis
and prognosis.
PREVENTION OF CARIES
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TABLE
1842-1908
Introduction of various restorative materials: gutta-percha, cohesive gold foil, zinc phosphate restorative material and
cement, silicate cement
1895-1935
First experiments with copper-containing amalgam and formulation of low-copper amalgam alloys
1962-1995
Development of high-copper and zinc-free, high-copper dental amalgam; fluoride-releasing dental amalgam; mercury-free
silver filling material
Dental Amalgam
1962
1968-1977
1984-2005
Development and commercialization of flowable, packable nano and trimodal composites for dental use
1955-1983
1972-1985
Introduction of glass ionomer restorative materials and glass ionomer admixture with amalgam alloy
1985
Introduction of glass ionomer materials for use with atraumatic restorative technique
1992
1860-1870
1920-1929
Development of first strict formulation of zinc phosphate cement, commercial cavity varnish and calcium hydroxide pulpcapping material
~1969
1903-1907
1937
Placement of the first Vitallium (Austenal Laboratories, now Dentsply Austenal, York, Pa.) screw implant
1955-1962
Development of titanium casting for single-unit and multiple-unit restorations; patenting of commercial porcelainbonded-to-metal system
1968
~1974- ~1985
Development of plastic extracoronal laminate veneers and subsequent intracoronal porcelain veneers
Adhesive Systems
Glass Ionomers
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TABLE (CONTINUED)
Development of rubber dam, foot-treadle dental engine (700 revolutions per minute [rpm]), electric dental engine (1,000
rpm), steel dental burs
1937
1942
Introduction of diamond cutting instruments, high-speed dental engine (>10,000 rpm) and tungsten carbide burs
1953
1955-1957
Development of water-turbine (50,000 rpm), belt-driven (150,000 rpm) and air-turbine (300,000 rpm) high-speed
handpieces
1973-1977
1980-1995
Development of carbon dioxide (CO2), neodymium-doped yttrium aluminum garnet (Nd:YAG), erbium-doped yttrium
aluminum garnet (Er:YAG) and erbium-chromiumdoped yttrium scandium aluminum garnet (Er,Cr:YSGG) hydrokinetic
lasers for dentistry
1993-1995
~1995-2000
1989
~1998
* Sources: Buonocore,83 American Dental Association,149 Bayne and Thompson,150 Bower and Marjenhoff,151 Gelbier,152 Mahler,153 Rueggeberg,154
Schulein,155 Thompson and colleagues156 and Wilwerding.157
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he contributions of
researchers in the United
States to scientific
advances in the biological
understanding, prevention,
diagnosis and treatment of periodontal diseases during the past 150
years have been characterized by scientific partnerships among a dedicated practicing profession, substantial public and private-sector research
activity, extensive international collaboration, and strong support from
the National Institutes of Health,
Bethesda, Md. This overview focuses
on the discovery of relationships
between dental plaque and the host
periodontal tissues, and it highlights
only a fraction of the pioneers who
shaped new approaches to periodontal
disease prevention and treatment.
Taken collectively, these efforts have
fundamentally changed our understanding of periodontal infections and
constitute a revolution in how clinicians treat patients with periodontal
disease.
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ABSTRACT
Background. Major scientific advances in periodontology in the
past 150 years have fundamentally changed how clinicians detect and
treat periodontal diseases. These advances include the demonstration
that gingivitis and periodontitis are biofilm-induced infections caused
by components of the indigenous oral microbiota, and that host
inflammatory-immunologic responses to these microbial challenges
are responsible for most of the observed tissue damage.
Types of Studies Reviewed. In this brief overview, the authors
focus on the discovery of the relationships between dental plaque and
the host periodontal tissues. They highlight some of the pioneers in the
United States who shaped new approaches to prevention and treatment
of periodontal disease.
Results. Biofilms that cause gingivitis and periodontitis are complex
polymicrobial communities that are resistant to antimicrobial agents
and host defense mechanisms. An increased understanding of natural
inflammation-resolving mechanisms suggests that control of inflammation is at least as important as is antimicrobial therapy in the treatment of periodontal infections. Data from randomized controlled clinical
trials have shown that most conventional forms of periodontal therapy
are effective as long as patients comply with posttreatment maintenance programs.
Conclusions. Many mechanisms involved in the repair and regeneration of periodontal tissues have been identified. Results of laboratory
studies of factors that enhance prevention and treatment of periodontal
disease have made the transition to clinical practice. Advances in the
fields of molecular biology, human genetics and stem cell biology have
set the stage for significant discoveries that will pave the way for the
development of procedures needed for the predictable regeneration of
periodontal tissues. As a result, new generations of people in the United
States can expect to retain a healthy and functional dentition for
a lifetime.
Key Words. Scientific advances; periodontology; dental history.
JADA 2009;140(9 suppl):36S-43S.
Dr. Armitage is the R. Earl Robinson Distinguished Professor, Division of Periodontology, Department
of Orofacial Sciences, School of Dentistry, University of California, San Francisco, 521 Parnassus
Ave., C-628, Box 0650, San Francisco, Calif. 94143-0650, e-mail Armitageg@dentistry.ucsf.edu.
Address reprint requests to Dr. Armitage.
Dr. Robertson is a professor and dean emeritus, School of Dentistry, University of Washington,
Seattle.
September 2009
periodontitis) harbored a disease-specific subgingival microbiota; this finding challenged the prevailing assumption that periodontosis was a degenerative disease and suggested strongly that the
disease was an infection.
According to Fine,10 the results of studies conducted by Theodor Rosebury and his students
Solon A. Ellison and John B. MacDonald of the
pathogenic potential and virulence of the aerobic
and anaerobic components of the indigenous oral
microbiota supported the concept that gingivitis
and periodontitis are infections. The advent of
improved laboratory methods for culturing anaerobic bacteria revealed that some bacteria in plaque
are more important than others as causative
agents of periodontal infections. Moreover, these
studies concluded that periodontal infections are
not caused simply by an increased quantity of
dental plaque on the teeth; rather, the composition
of the microbial community is of considerable etiologic importance.10 A historical review11 of evidence
supporting the bacterial etiology of periodontal diseases includes many scientists who contributed to
these major advances in periodontal microbiology,
notably Ronald J. Gibbons, Sigmund S. Socransky, Anne D. Haffajee and Anne C.R. Tanner
at the Forsyth Institute, Boston, and Lillian V.
(Holdeman) Moore and William E.C. Moore12 at the
Virginia Polytechnic Institute, Blacksburg, Va.
Walter J. Loesche13 summarized this concept in
a discussion of nonspecific versus specific
hypotheses regarding the microbial etiology of
periodontal infections. Some authorities, including
Rosebury, favored the nonspecific plaque hypothesis in which increased numbers of indigenous bacteria (that is, an increased plaque biomass) overwhelm host defenses and result in periodontal
disease. Other investigators, such as MacDonald,
favored the specific plaque hypothesis in which a
small number of specific bacteria are responsible
for triggering the tissue damage observed in
inflammatory periodontal diseases.10
In the 1990s, Socransky and colleagues14 used
cultivation methods and DNA probe technology to
show statistically significant associations between
clusters of indigenous bacteria in the subgingival
microbiota and the presence and progression of
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highly likely that the other, yet-to-becultivated 50 percent contains microorganisms that are of etiologic importance or play important roles in
biofilm ecology. Many investigators
are applying gene-detection methods
to determine the presence of uncultivable components of dental
biofilms.19-22 What has emerged from
this work is the extraordinary diversity of oral microbiota in health and
disease. It is likely that this work will
lead to a better understanding of how
oral biofilms form, mature and
interact with the host to cause disease. Novel treatment approaches and
intervention strategies will result
Researchers at a National Institute of Dental Research conference on dental plaque
from
discoveries dealing with the
(Airlie Center, Warrenton, Va.; circa 1975). Kneeling (left to right): Ernest Newbrun,
mechanisms
of biofilm-host
Walter Loesche, Harald Le, Robert Genco, Thomas Valega. Standing (left to right): Paul
Keyes, unknown, Ronald Gibbons, Sigmund Socransky, Roy Page, William Bowen,
interactions.
Anthony Rizzo, Thomas Temple, Jan Carlsson, James English, John Goggins, Bernard
Advances in pathogenesis of
Guggenheim, Max Listgarten, William McHugh, Robert Fitzgerald. Photograph courtesy
of Richard Ellen. Reproduced with permission of Marcia Gibbons.
periodontal diseases. The early history of periodontal pathogenesis was
periodontitis. It became clear that bacteria such as
dominated by the premise that all people are
equally susceptible to developing periodontitis and
Porphyromonas gingivalis, Tannerella forsythia,
that untreated gingivitis progresses to periodonTreponema denticola, Campylobacter rectus,
titis linearly over time. On the basis of general
Micromonas micros, Streptococcus intermedius,
medical pathology models, researchers believed
Eubacterium nodatum, Aggregatibacter (formerly
that most of the destruction of periodontal tissues
Actinobacillus) actinomycetemcomitans and Preduring the course of the disease was due to inflamvotella intermedia are important members of the
matory or degenerative/atrophic processes.23 Until
consortium of microorganisms that cause
periodontitis.
the late 1960s, researchers based their studies priThe major microbiological conclusions estabmarily on observations and individual interpretalished during this period include the following:
tions of the histologic changes in the diseased tisdperiodontal infections are polymicrobial;
sues. A consistent observation was that the
dthe causative agents are part of the indigenous
affected tissues were chronically inflamed at both
(normal) microbiota;
the clinical and histologic levels. Unfortunately,
dthe amount of dental plaque is of etiologic
the results of morphological studies alone were
importance;
unable to explain the mechanisms responsible for
dsome bacteria in dental plaque are more pathothe tissue destruction at inflamed sites.
genic than others.
When the results of microbiological studies
Of equal scientific importance was the demonshowed clearly that gingivitis and periodontitis are
stration by several groups, including those led by
infections, investigators began to unravel the comJohn W. Costerton and colleagues15 and Paul E.
plex mechanisms of how bacteria could trigger
Kolenbrander and colleagues,16 that dental plaques
destructive inflammatory responses by the host. In
are highly organized bacterial biofilms. From a
addition, innovative ultrastructural studies contherapeutic perspective, these biofilms are complex
ducted by Max A. Listgarten24 clarified the relapolymicrobial communities that are resistant to
tionship of junctional epithelium to the tooth. He
externally applied antimicrobial agents and
also made major contributions to understanding
antibacterial host mechanisms.17
interactions between microbiota and periodontal
It is now known that only about 50 percent of
tissues in health and disease.25
the oral microbiota can be grown in the laboratory
In 1976, Roy C. Page and Hubert E. Schroeder26
18
by using modern cultivation techniques. It is
documented a dynamic series of inflammatory
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response and the natural mechanisms of its resolution suggests that control of inflammation is at
least as important as is antimicrobial therapy in
the treatment of periodontal infections.38 Future
models of the pathogenesis of inflammatory periodontal disease will incorporate genomic, proteomic
and metabolomic data into dynamic biological networks that include mechanisms of disease initiation and resolution.39
Potential effect of periodontitis on general
health. During the past two decades, investigators
have reexamined the possibility that untreated
periodontal infections can have an adverse effect on
general health and that other diseases can contribute to periodontal pathogenesis. The results of
these studies40-42 suggest that untreated periodontitis may be a risk factor for myocardial infarction,
nonhemorrhagic strokes and adverse birth outcomes. In addition, evidence indicates that periodontal infections may interfere with the metabolic
control of diabetes mellitus.40 The presence of such
associations may reflect risk factors common to
periodontitis and other chronic inflammatory diseases. Although this is a highly important area of
ongoing investigation, the results of observational
and interventional studies vary and the relationship between periodontal disease and general
health remains unclear.
PREVENTION AND TREATMENT
OF PERIODONTAL DISEASES
Dental calculus. Long before investigators recognized that gingivitis and periodontitis are infections caused by indigenous oral microbiota, many
clinicians observed that the frequent removal of
acquired deposits from teeth resulted in a noticeable improvement in overall periodontal health.
This observation led influential clinicians such as
John W. Riggs43 and G.V. Black44 to conclude in the
1880s that dental calculus was a major local irritant that caused periodontal inflammation. However, no universal consensus existed with regard to
this issue.1,2 As a result of the confusion regarding
the etiology of periodontitis, treatment included a
range of therapies including dietary changes, gingival massage, local application of caustic chemicals, occlusal adjustment, ingestion of patent remedies, removal of local irritants and surgical
resection of affected tissues. In some situations,
dentists and patients considered periodontal disease to be untreatable, with tooth extraction being
the ultimate management strategy.
At the beginning of the 20th century, there were
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likely will lead to novel therapeutic ways to interfere with and disrupt these disease-producing
biofilms.
Repair and regeneration. Throughout the
first half of the 20th century, many authorities,
including Black, believed that once periodontal tissues were detached from the teeth as a result of
periodontitis, there is no chance whatever for a
reattachment.68 Although this view was not held
universally, it was the prevailing opinion until clinicians began publishing practice-based series of
cases in which therapy resulted in the clinical closure of periodontal pockets with radiographic evidence of osseous repair. Among these publications
was a report by John F. Prichard69 in which treatment resulted in dramatic osseous repair, especially of narrow three-walled defects.
As the field of periodontics matured from 1970 to
2000, investigators in many controlled studies evaluated the effects of periodontal flap procedures
alone compared with flap procedures combined
with the insertion of various bone-replacement
graft materials. In a systematic review and metaanalysis of these studies, Reynolds and colleagues70
concluded that bone-replacement grafts resulted in
statistically significantly increased bone and clinical attachment levels and reduced probing depths
compared with flap procedures alone.
Guided tissue regeneration. The next major
advance in periodontal regeneration was the proofof-principle introduction of guided tissue regeneration (GTR) procedures in 1982. Sture Nyman and
colleagues71 placed a barrier membrane between
the periodontal flap and a tooth scheduled for
extraction in a patient with severe periodontitis.
This procedure temporarily excluded the gingival
epithelium and connective tissue from the osseous
defect and allowed pluripotent cells from the periodontal ligament to colonize the wound. The results
of histologic studies showed partial regeneration of
lost periodontal tissues, including the formation of
new cementum, bone and a functional periodontal
ligament.71 Subsequent investigations reviewed in
a meta-analysis72 of the clinical effectiveness of
GTR procedures suggest that these procedures can
promote gains in clinical attachment levels and
reductions in probing depths.
Also during the past two decades, researchers
have shown an increasing interest in studying the
role of growth factors in tissue repair and regeneration.73,74 Growth factors are naturally occurring
mediators produced by a variety of cells that affect
the complex cascade of events during wound
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CONCLUSIONS
45. Stern IB, Everett FG, Robicsek K. S. Robicsek: a pioneer in the surgical treatment of periodontal disease. J Periodontol 1965;36(4):265-268.
46. Younger WJ. Pyorrhea alveolaris. American Medical Association:
section on oral and dental surgery (proceedings). Dent Cosmos 1894;36:
726-733.
47. Goldman HM. The development of physiologic gingival contours by
gingivoplasty. Oral Surg Oral Med Oral Pathol 1950;3(7):879-888.
48. Glickman I. The results obtained with an unembellished gingivectomy technique in a clinical study in humans. J Periodontol 1956;27(4):
247-255.
49. Schluger S. Osseous resection: a basic principle in periodontal
surgery. Oral Surg Oral Med Oral Pathol 1949;2(3):316-325.
50. Bunting RW. The control and treatment of pyorrhea by subgingival
surgery. JADA 1928;15(1):119-126.
51. Hirschfeld I. The Toothbrush: Its Use and AbuseA Treatise on Preventive Dentistry and Periodontia as Related to Dental Hygiene; With 174
Case Histories and 415 Illustrations. Brooklyn, N.Y.: Dental Items of
Interest Publishing; 1939:43-110.
52. Merritt AH. Treatment of periodontoclasia by subgingival curettage.
JADA 1932;19(2):279-281.
53. Bell DG. The pathologic pocket and its treatment by instrumentation. JADA 1933;20(1):129-133.
54. Ramfjord SP, Nissle RR, Shick RA, Cooper H Jr. Subgingival curettage versus surgical elimination of periodontal pockets. J Periodontol
1968;39(3):167-175.
55. Ramfjord SP, Knowles JW, Nissle RR, Shick RA, Burgett FG. Longitudinal study of periodontal therapy. J Periodontol 1973;44(2):66-77.
56. Ramfjord SP, Knowles JW, Nissle RR, Burgett FG, Shick RA.
Results following three modalities of periodontal therapy. J Periodontol
1975;46(9):522-526.
57. Knowles JW, Burgett FG, Nissle RR, Shick RA, Morrison EC, Ramfjord SP. Results of periodontal treatment related to pocket depth and
attachment level: eight years. J Periodontol 1979;50(5):225-233.
58. Ramfjord SP, Caffesse RG, Morrison EC, et al. 4 modalities of periodontal treatment compared over 5 years. J Clin Periodontol 1987;14(8):
445-452.
59. Ramfjord SP. The periodontal disease index (PDI). J Periodontol
1967;38(6):33/605.
60. Pihlstrom BL. Sigurd Ramfjord and Major Ash, Jr.: periodontology
and occlusion at Michigan. J Dent Res 1997;76(11):1716-1719.
61. Heitz-Mayfield LJ, Trombelli L, Heitz F, Needleman I, Moles D. A
systematic review of the effect of surgical debridement vs non-surgical
debridement for the treatment of chronic periodontitis. J Clin Periodontol
2002;29(suppl 3):92-102.
62. Heitz-Mayfield LJ. How effective is surgical therapy compared to
nonsurgical debridement? Periodontol 2000 2005;37:72-87.
63. Le H, Schitt CR. The effect of mouthrinses and topical application
of chlorhexidine on the development of dental plaque and gingivitis in
man. J Periodontal Res 1970;5(2):79-83.
64. Hallmon WW, Rees TD. Local anti-infective therapy: mechanical and
physical approachesa systematic review. Ann Periodontol 2003;
8(1):99-114.
65. Pitcher GR, Newman HN, Strahan JD. Access to subgingival plaque
by disclosing agents using mouthrinsing and direct irrigation. J Clin Periodontol 1980;7(4):300-308.
66. Hanes PJ, Purvis JP. Local anti-infective therapy: pharmacological
agentsa systematic review. Ann Periodontol 2003;8(1):79-98.
67. Haffajee AD, Socransky SS, Gunsolley JC. Systemic anti-infective
periodontal therapy: a systematic review. Ann Periodontol 2003;8:
115-181.
68. Black GV. A Work on Special Dental Pathology. 2nd ed. Chicago:
Medico-Dental Publishing; 1924:166.
69. Prichard J. The infrabony technique as a predictable procedure. J
Periodontol 1957;28(3):202-216.
70. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley
JC. The efficacy of bone replacement grafts in the treatment of periodontal
osseous defects: a systematic review. Ann Periodontol 2003;8(1):
227-265.
71. Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982;9(4):290-296.
72. Murphy KG, Gunsolley JC. Guided tissue regeneration for the treatment of periodontal intrabony and furcation defects: a systematic review.
Ann Periodontol 2003;8(1):266-302.
73. Giannobile WV, Somerman MJ. Growth and amelogenin-like factors
in periodontal wound healing: a systematic review. Ann Periodontol 2003;
8(1):193-204.
74. Slavkin HC, Bartold PM. Challenges and potential in tissue engineering. Periodontol 2000 2006;41:9-15.
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ABSTRACT
Background. New tools are enabling researchers to understand the
mysteries of oral biology and disease and to change profoundly the treatment of oral, dental and craniofacial diseases and disorders. The authors
explore advances in modern science and technology and how they will
change oral health care in the future.
Results. Emerging technologies such as salivary diagnostics, highresolution imaging and nanotechnologies, as well as other new tools will
lead to efficient and highly effective personalized dental treatments. A
new generation of cell-based therapies will be available for regenerating
tissues, and anti-inflammatory drugs and pain medications will be tailored to maximize efficacy and safety. Large teams of clinicians and scientists will tackle increasingly complex problems, and advances in computational sciences will make it possible to create virtual teams across the
world. Information technology systems will enable clinicians to examine
and integrate information obtained from all databases in cyberspace.
Clinical Implications. As scientists discover newer and better
methods to preempt and prevent disease, they must translate these
methods into tools for people at greatest risk of developing disease. Conquering the array of complex diseases that affect the oral and craniofacial
complex will require multifaceted strategies and multidisciplinary
cooperation.
Key Words. Dental research; emerging technology.
JADA 2009;140(9 suppl):44S-48S.
Dr. Garcia is the deputy director, National Institute of Dental and Craniofacial Research, National
Institutes of Health, 31 Center Drive, Building 31, Room 2C39, Bethesda, Md. 20892, e-mail
GarciaI@mail.nih.gov. Address reprint requests to Dr. Garcia.
Dr. Tabak is the director, National Institute of Dental and Craniofacial Research, National Institutes
of Health, Bethesda, Md.
September 2009
The visual and tactile methods of dental diagnostics will be augmented by powerful technologies
such as smart imaging systems, genome scans to
evaluate patients responses to pharmaceuticals,
molecularly based diagnostics and integrated electronic risk management systems. Dentists of the
future will rely on a range of diagnostic and treatment tools that rapidly and efficiently process a
patients biological information, from their genes to
their proteins to their metabolites.
DENTISTRY IN THE FUTURE
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complications such as scarring, contracture or dysfunction. People with inflammatory diseases will
benefit from a new generation of anti-inflammatory
drugs that will enhance resolution of the immune
response via natural signals to heal and cease the
inflammation, rather than via an attempt to interrupt the immune response. In addition, the large
number of people with chronic orofacial pain conditions will be treated with a new generation of nonaddictive pain medications that will be tailored for
them through the use of pharmacogenomic principles to maximize efficacy and safety while avoiding
dangerous side effects.
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ties if used to root out causes of disease, to reprogram the biology of disease and to target the most
vulnerable people for early intervention. However,
investing in healthy communities and developing
social and economic policies that increase opportunities, education and access to quality health care
will go a long way toward breaking the cycle of
health inequalities. Now is the time for policymakers to consider undertaking a vigorous debate
about how scientific advances could improve the
publics health, given the complexities of our health
care delivery system and the economic and cultural
differences that constitute our nation.
CONCLUSIONS
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