A CONVERSATION WITH VAN THOMPSON, DDS, PHD, AND PETER BLANCHARD, DDS, MBA
Recently, Drs. Thompson and Blanchard sat down with Global Health Nexus to talk about the wide-ranging potential and the challenges of new applications for the use of biomaterials in dentistry.
Dr. Blanchard: As a private practitioner, I consider access to reliable research to be the greatest challenge to the use of biomaterials in private practice. Private practitioners are deluged with all kinds of advertising promoting new materials. Figuring out which materials work best is very difficult.
Dr. Thompson: That's why the research undertaken by the PEARL network is so important. By networking dental practices in research projects, PEARL allows us to begin to look at the outcomes of various techniques and to keep track of the latest biomaterials so that more detailed studies can evolve.
Dr. Blanchard: It's usually top down in the research community. But with the PEARL Network, this is really bottom up—dealing with the issues that frustrate dentists in their everyday practice. Research conducted by the PEARL Network has such great potential because it can inform our in-office clinical trials, and our results can help to frame the model for future trials.
The dental community is different from medicine because it's really a cottage industry. Other healthcare fields are organized into larger group practices and university-based research. I graduated from Georgetown, went into practice, and lost all contact with my academic institution. With its roster of distinguished practice-based researchers, the PEARL Network has helped me to realign my practice with academic research and gain access to quality information. PEARL is actively investigating biomaterials in a "real-world" setting. This work speeds the translation of research into practice and facilitates building more effective patient-care protocols.
But it's also a matter of changing dentists' mindset. In dentistry, the insurers and the payer system motivate practitioners to treat dental disease surgically. At PEARL, we want practitioners to start thinking in terms of disease management, recognizing that caries and periodontal disease are chronic, infectious diseases of the mouth. We have available chlorhexidine and other antibacterials that reduce the numbers of bacteria causing these chronic diseases. Some naturally occurring sugars such as xylitol also help suppress bacteria. Using agents such as fluorides and calcium phosphate also helps heal the tooth. If we can actually remineralize teeth and catch a cavity early on, we can reverse the chemical equation, drive the minerals back into the tooth, and heal that cavity. Most people don't realize this.
Dr. Thompson: Yes, there is a shift going on in the biomaterials world regarding how to best deliver remineralization solutions. And again, the intent, as you point out, is a push toward management of the disease. PEARL is now looking into studies on ways to determine when caries is present in early stages and into developing a mechanism to report this in a patient record so that a dentist can follow his or her patients. In doing so, PEARL has the potential to help promote the use of diagnostic codes in dentistry.
Dr. Blanchard: Then we could use diagnostic codes to better communicate with the insurers, which could lead to very significant plan redesigns. For example, if a patient is assessed as high risk, their insurance benefit would then increase dramatically in terms of the preventive therapies we could use to help remineralize and control the infection.
Dr. Thompson: We could also research biomaterials that might be used in those individuals to deliver remineralization therapy, perhaps through biomaterials that we bond to the teeth, which contain or release a combination of specific forms of fluoride, calcium, and phosphate.
At NYU, we are currently developing calcium phosphate scaffolds for generating new bone. We're also working on creating high-strength ceramics. This would offer an alternative for people interested in the best aesthetics who also have some concerns about metals in the mouth. However, these studies are not at the practice-based research level yet.
Dr. Blanchard: This is where PEARL can help. I feel that the key to PEARL's effectiveness is its ability to build a cadre of practitioners who are skilled and knowledgeable in conducting quality research and in applying the results in private practice. So much university-based research doesn't mirror the daily challenges of a private practice.
Dr. Thompson: They serve different purposes. In clinical trials conducted at NYU, we look at a select group of patients with one or two researchers performing all the work and then looking at that outcome over an extended period of time. With PEARL, we have what is called effectiveness research—a broad group comprised of 40 or 50 dental practices and practitioners using the biomaterials and conducting research, thereby broadening the user as well as the recipient base.
Dr. Blanchard: Part of the Surgeon General's 2000 report recommended speeding the translation of research into private practice since it generally takes about 15–20 years for fundamental discoveries in lab research to be implemented.
Dr. Thompson: That recommendation is in keeping with PEARL's mission. For example, PEARL has been looking at problems of post-operative hypersensitivity on the biting surfaces of the teeth. We are evaluating resin-based composite restoration along with particular bonding agents and liners, or a combination of the two. The PEARL practitioners implementing these materials and techniques then engage their patients in follow-up, to find out whether they have sensitivity, and then we monitor that sensitivity over time.
Dr. Blanchard: And now we are getting ready to start a very challenging randomized clinical trial to look at sensitivity with lesions at the gum line. Many patients suffer from hypersensitivity to hot, cold, and sweet sensations because of these kinds of lesions. There is a wide range of desensitizing agents in use. The current study is designed to look at three of the more popular agents, including a desensitizing toothpaste, a resin sealant, and a flowable composite, to determine which is most effective.
Dr. Thompson: Sensitivity with lesions at the gum line is a familiar problem. We believe it's related to a combination of prominence of a tooth that is exposed to brushing and a tendency to brush aggressively, which wears down the root and exposes the dentin itself.
Dr. Blanchard: So many products purport to treat hypersensitivity, and we have varied results. PEARL's research is designed to really nail it down, so that we can better communicate with our patients, and they'll trust that we have a viable solution. We can then make evidence-based decisions rather than simply say, "This is the greatest product that ever came down the pike."
Eventually, we hope that manufacturers may even consider coming to a respected practice-based research network such as PEARL and saying, "Here's a product with great potential. Let's try it in the 'real world' and evaluate its efficacy."
Dr. Thompson: I think that's a very astute point. And we think the field of dentistry will look to us as well. But it's an evolutionary process.
Conducted, condensed, and edited by Stephanie Susnjara