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Dental education, like any other educational programme in a research-intensive university environment, must be research led or at least research informed. In this context, as the research and knowledge base of dentistry lies in the biological and physical sciences, dental education must be led by advances in research in both these areas. There is no doubt that biotechnology and nanotechnology have, over the past 25 years, led research in both these areas. It is therefore logical to assume that this has also impacted on dental education. The aim of this paper is twofold; on one hand to examine the effects of biotechnology and nanotechnology and their implications for dental education and on the other to make recommendations for future developments in dental education led by research in biotechnology and nanotechnology. It is now generally accepted that dental education should be socially and culturally relevant and directed to the community it serves. In other words, there can be no universal approach and each dental school or indeed curriculum must apply the outcomes in their own social, cultural and community settings.
Biomedical science and technology are fields at the forefront of medical and dental research. They are areas attracting public attention and research funding and have delivered outcomes beginning to contribute greatly to our understanding, diagnosis, treatment and prevention of human disease. The potential for future applications to human health, including oral health is enormous. The significant impact on the practice of dentistry together with the rate and magnitude of change in biotechnology demand that our profession and curricula respond. As well as changes in the way dentistry will be practised, there are legal and ethical issues arising from these new technologies. Dental students must be equipped to deal with the changing face of dental practice.
Biomedical science and technologies are terms referencing the application of biologic knowledge and techniques to improve human health. This is a rapidly growing area with significant economic force. Genetic medicine, the area of biotechnology most relevant to human health, is based on genomics, the study of genes and their role in health and disease. Genomics aims at understanding the function of the human body and the processes occurring in disease at the most fundamental level. Biotechnology also encompasses nanotechnology, the building of molecular structures which can function as machines or devices on the nanometre scale, for example gene chips (1). Under this definition, genetic manipulation to alter the products of a cell can be classed as nanotechnology. Nanotechnology is also being applied to drug and vaccine delivery systems which will clearly have an important impact on dental practice.
Developing in parallel with biotechnology is bioinformatics. Examination of the genome (genomics), the messenger RNA transcribed from active genes (transcriptomics), the proteins coded for by this mRNA (proteomics) and the metabolites which are the end products of gene expression (metabolomics) all use techniques which result in extraordinary amounts of data. This necessitates the use of computer science, mathematics and information theory to model and analyse these systems (bioinformatics) (Fig. 1).
These new technologies have led to ‘the golden age of molecular oral health’ (2) and research has resulted in the convergence of the clinical sciences, information sciences and biotechnology. The development of sophisticated new research tools has given researchers new ways to ask old questions and as a result, much has been learnt of the molecular basis of oral diseases in the last decade. The definition of disease is also changing. Previously, disease was understood to be the presence of symptoms or of a particular phenotype. With increasing knowledge of the genetic basis of many diseases, this definition is changing to become the presence of a genotype conferring a pre-disposition to clinical symptoms or phenotype. Whilst this will translate into earlier diagnosis, enabling more targeted effective prevention and treatments resulting in healthier and more long-lived patients, the ethical implications of this change in definition are profound. It must be remembered that pre-disposition to disease is in itself not the disease. From an oral health perspective, this is particularly relevant for many of the syndromes affecting the head and neck, as well as for more common diseases such as periodontal disease where it is well recognized that patient susceptibility determines the ultimate outcome of both the disease and its treatment. In terms of head and neck cancer, genetic pre-disposition to environmental risk factors such as alcohol and tobacco has been identified and may help to identify individuals at risk. As mentioned above, the major oral diseases of caries and periodontal disease are complex diseases resulting from an interaction between bacterial, genetic and environmental factors. An understanding of these conditions at the molecular level, however, will be much more difficult than for simple hereditary disorders such as hypodontia, amelogenesis imperfecta and dentinogenesis imperfecta. Nevertheless, because of the high prevalence of periodontal disease, and its association with other systemic diseases, using molecular techniques to understand susceptibility and target prevention and treatments appropriately may provide significant public health benefits.
Because of our increasing awareness of the molecular basis of cellular responses, the emerging area of tissue engineering, including the use of pluripotent stem cells, is gaining attention and has great potential to impact on our future practice of dentistry. Similarly, with new technologies we have the ability to understand at a molecular level, the cellular processes and interactions of the microorganisms involved in oral diseases. Bacteria have been populating the globe for the last 3–4 billion years, such that multicellular organisms, including humans, have had to adapt to the presence of this microbial community. Contemporary genomic and proteomic research outcomes give some evidence for the molecular–biological background of this symbiosis of life. This means that the virulence and pathogenicity of certain microbial species is a biological exception, developing in the presence of host susceptibility and resulting in pathologic conditions. Therefore, the knowledge of the aetiology and pathogenesis of most dental diseases is changing as a result of this realization which, in turn, is impacting on our diagnostic and treatment strategies.
The major oral disease of dental caries is a complex and, after manifestation, a lifelong chronic disease, resulting from the interaction of pathogenic environmental biofilm factors with genetic host responses via saliva secretion and soft tissue reactions. New genomic and proteomic techniques are providing insight into the molecular background of bacterial cell–cell communication, of host cell–cell communication as well as bacterial to host cell interaction. Risk assessment by DNA diagnostic tests and enhancement of early remineralization of enamel and dentine lesions will, in the not too distant future, contribute to non-invasive caries treatment. However, carious cavitation and trauma to teeth will not disappear and, therefore, restorative biomaterials are needed for the future.
Major advances in biomedical science and technologies
Knowledge has grown in the fields of genomics, proteomics, the study of molecular control mechanisms and in materials and biomaterials primarily as a result of advances in biomedical techniques (Figs. 2 & 3).
In 1990, the ambitious Human Genome Project (HGP) commenced. A draft of the human genome was published in 2001 and the project was completed in 2003, with 99% decoded. Mapping the genome, however, was only the first step. Much research is currently seeking to determine how these genes perform their functions and how this varies under different conditions. Gene–gene and gene–environment interactions further complicate our understanding of the function and regulation of the genome. The HGP provided the information required to initiate an explosion of research projects investigating the molecular basis of human health and disease. The genetic basis of many diseases is currently being unravelled. This involves not only the identification of particular genes associated with disease but also the mutations and polymorphisms of these genes which may determine disease susceptibility. This may also include the non-protein coding regions (98.5%) of the genome which appear to be important in the regulation of the pattern and magnitude of protein expression in different cells. The genome of a number of other mammals and microorganisms is now also known. The mouse genome was particularly valuable for research as mouse models are commonly used to study disease processes and to evaluate potential new therapies. Knowledge of microbial genomes is also important as this has enabled technologies to detect and quantitate specific organisms and strains accurately. It has also allowed the study of genes coding for virulence factors and their association with disease.
The Human Genome Research Institute has established a funded Ethical, Legal and Social Implications Research Program to explore these aspects of genetic research. The recognition of the importance of these ethical, legal and social issues is fundamental to the success in translating research outcomes in this field to health benefits in a way which is acceptable to our varying social, cultural and community settings. Because of the enormous scale of the HGP, in terms of finances, expertise and logistics, it was necessary for researchers to come together to form large interdisciplinary teams. Traditionally, biological research was performed by individuals or small groups. This project marked the transition to team-oriented research. Indeed, most biotechnology research now requires large teams with researchers from a number of institutions and backgrounds working together collaboratively. This has implications for dental research. It is important if we wish to remain competitive in terms of impact and funding, that we adapt our research structure and culture to embrace collaborations and techniques from outside our own fields. Traditional funding approaches that encourage competition are in fact failing not only with respect to dental research but in many other fields as well. New funding models have to be developed if dental research, and hence the practice of dentistry, is to continue to develop.
Proteomics is the study of the products of the 2% or less of the human genome which is transcribed – that is, protein coding. These proteins undergo substantial post-translational modification (proteolysis, glycosylation, etc.) resulting in a number of different products from a single gene; 30,000 human genes code for 400,000 or more proteins. Analysis of the proteome is facilitated by two-dimensional electrophoresis, liquid chromatography and rapidly developing new microanalytical procedures. Samples, as small as a few microlitres, can now be studied. Proteins and peptides can be identified by mass spectrometry, polymerase chain reaction (PCR) and microarrays. The results can be analysed by computer and also by reference to international databases. These techniques have led to the development of new diagnostic approaches, which have allowed minute quantities of diagnostically important proteins and molecules to be detected in body fluids such as saliva. Salivary diagnostics form a growing and potential important approach to human disease.
Over the last two decades there have been advances in our understanding of molecular communication within and between cells. In tissues, cells communicate with each other and are influenced by matrices via small peptides or chains of interactions. Cell function is controlled by external molecules which trigger cell membrane molecules – either messenger or permeability molecules – and cause activation of internal molecular messages. These processes are fundamental to development, growth, function (secretion and movement) and even death (apoptosis) of the cell. Thus, tissue engineering depends on growth factors and other molecular messengers; immunotherapy and antiviral and antimicrobial actions involve molecular pathways and signals.
Biomaterials research is shifting from testing of ‘synthetic biomaterials’ to developing and testing ‘biological biomaterials’ (3). In this context, two research directions will determine future education and clinical procedures. These are: (i) characterization of the structure–property events within synthetic and biological restorative materials and (ii) the interactions at their interfaces with oral tissues and vice versa. In addition, translational research into the long-term clinical performance of these new restorative materials will need to be carried out. In this context, the importance of practice-based research methodologies is increasingly being recognized.
Tissue engineering and the vision of ‘building new teeth’ (4) will not replace restorative biomaterials in the near future. Therefore, new classes of composite materials with non-toxic molecular structure and well-characterized interactions with the pulp-dentine organ, improved alloys and new ceramic materials with tooth-like properties are expected to be developed and biologically tested. Stem cells of the dental pulp could be differentiated into regenerative cells by the application of signal molecules so far unidentified. Dental education and clinical dental medicine have to take into account that the human dentition, with slow but continuous eruption (5), is ‘intended to last a lifetime’ (6).
Impact of biotechnology on clinical practice
A greater understanding of the biological basis of caries has, over the past two decades, led to dramatic changes in the way it is treated, for example greater emphasis is now placed on remineralization. Similarly, exploration of the molecular basis of human health and disease has resulted in the emergence of a predict, prevent and manage paradigm. If we understand the genetic basis of a condition and have the tools and resources to investigate this for our patients, we will no longer have to wait until signs or symptoms become clinically evident. Often, by this stage there will have been significant damage to the body’s cells and tissues, and treatment will need to be reparative. If genetic risk is determined to exist for a patient, then we can institute measures aimed at preventing the onset or minimizing the extent of that condition. It would follow that patient care would become increasingly focused on prevention of disease and the maintenance of health. Although healthcare costs for these diagnostic and preventive visits could be significant, the savings by reduction of disease prevalence and severity could be enormous. Financial benefits would be direct in the form of reduced public health expenditure for treatment of disease and indirect in the form of increased workforce productivity as the levels of sickness and disability resulting from disease would be lower. Overall, the emphasis would be on disease prevention, health promotion and the creation of healthy communities – a view of health as a whole and as much more than merely the absence of symptoms (1). In dentistry, we have seen advances in biotechnology make possible applications that are the result of the convergence of many fields, including tissue engineering, materials science, nanotechnology and stem cell biology.
An interesting change that has accompanied the rapid advances in biotechnology has been the change in attitudes and awareness of patients. Heightened public interest and the easy access of information through the Internet regarding treatment advances available to patients have changed the nature of the practitioner/patient relationship. Patients are more questioning and less accepting of their doctor or dentist’s diagnosis and treatment. They have increased expectations and there is a move towards more active participation by patients in their healthcare. Although these changes bring challenges for the way practitioners relate to their patients, they also bring increased opportunities for prevention that come with a more receptive and motivated patient.
Elucidation of the genetic basis for many diseases will enable DNA diagnostic tests for disease susceptibility. This has implications for tailoring treatments to particular patients as well as targeting treatments to those determined to be at risk. Genomic locations where a single nucleotide is altered are known as single nucleotide polymorphisms (SNP). Techniques are now available to detect SNPs thought to be responsible for susceptibility to a number of diseases. Knowledge of how different genotypes respond differently to different drugs (pharmacogenomics) may lead to the targeting of drug regimes to populations thereby increasing their effectiveness and reducing side effects. Cytochrome p450 polymorphisms, for example, affect the rate of drug metabolism in an individual. Drug doses could therefore be more accurately determined if this particular polymorphism was identified for a patient (7). Concomitant with these developments, however, are their ethical implications, many of which are not yet recognized.
Microbiological analysis has and will increasingly become DNA based, replacing traditional culturing. It provides faster, more reliable and detailed information used to identify species, strains, virulence factors and drug resistance. Knowledge of the genomes of pathogens allows us to characterize microorganisms more fully and facilitates the development of therapeutics such as vaccines and targeted drugs. The reduced prevalence of vaccine preventable disease has heightened the public perception of the potential adverse effects of vaccination. There is therefore increasing pressure to develop vaccines that provide greater levels of safety to maintain the ‘herd immunity’. Biotechnology allows the manipulation of the pathogen genome to produce attenuated strains; purification and synthesis of microbial components; expression of vaccine proteins in live vectors; and induction of appropriate immune responses. Alongside this, the molecular regulation of immune responses is being elucidated, resulting in vaccines with increased safety and efficacy. Improvements are being made on existing vaccines, new vaccines are being developed for other infectious diseases and there is progress in the development of vaccines for non-infectious diseases such as cancer (8). We have recently seen the introduction of a vaccine against human papillomavirus cervical cancer: the first anti-cancer vaccine to be widely available. The cost of development and production of these vaccines, however, is great and there is a danger that the focus will be on targeting the needs of developed countries rather than on the larger needs of poorer developing countries. Government regulation and financial subsidy may be needed as well as input from groups representing the ethical interests of society.
As previously discussed, tissue engineering has the potential to have a significant impact on the practice of dentistry. This has resulted in the emergence of ‘regenerative dentistry’ which aims to ‘restore tissue function through delivery of stem cells, bioactive molecules or synthetic tissue constructs engineered in the laboratory’ (9). In general medicine, there has been progress in the development of blood products, blood vessels, skin and bone, using tissue engineering and these are already achieving clinical success. Salivary gland gene therapy (10) is an area of current research, with the possibility of the development of treatment for damaged salivary glands (because of factors such as radiotherapy and Sjogren’s syndrome). Additionally, as salivary glands produce and excrete large amounts of protein they may be suitable targets for therapeutic gene transfer. Although this is an exciting development, the translation of success in current animal models to human applications is difficult and lengthy.
Knowledge of the genome of a number of important oral pathogens has led to improved understanding of virulence factors and host responses in dental caries, periodontal disease and candidiasis. Genomics and proteomics have been used to examine the nature of the host response and to provide opportunities for new therapies. Gene chips for these bacteria are being developed to facilitate the study of gene expression under a range of physiological conditions, including growth in biofilms. The genetic basis of oral cancers and the effect of environmental and viral agents can be studied using microarray techniques. This may allow early detection of pre-neoplastic lesions and development of novel targets for pharmaceuticals (11). Individualized treatments based on an understanding of the molecular characteristics of both the tumour and the patient may then be developed. Because of their ready accessibility, oral fluids are highly suited for diagnostic tests. A subset of the salivary transcriptome (mRNA) has recently been shown to predict oral cancer with a discriminatory power of 91% for both sensitivity and specificity (12).
Genes associated with several dental conditions including hypodontia, amelogenesis imperfecta and dentinogenesis imperfecta have been identified, so it is possible to determine if there is a genetic basis to an individual’s condition. The genetic factors influencing dental caries risk include tooth form, composition and arrangement, as well as salivary factors. An understanding of these characteristics, along with knowledge of the genetic traits of the cariogenic microorganisms involved gives a more complete picture of the molecular basis of caries risk. Currently however, public health measures such as fluoridation are likely to be more effective than molecular-based interventions. Periodontitis has a genetic as well as a microbial basis. Host susceptibility is known to be a major factor in determining disease progression and this is largely hereditary. Several genes that modify the immune response have been associated with periodontal disease but genetic markers for the identification of at risk individuals are still elusive. This is probably because of the interactions of multiple genes, which are in turn modified by environmental factors (13). Nevertheless, preliminary studies using microarray technology have already reported differential gene expression in gingivitis and periodontitis tissues and patients. It is therefore likely that understanding of why some people lose their teeth whilst others, carrying the same pathogenic organisms, do not, will lead to better diagnostic and better treatment strategies in the not too distant future.
As technology improves, production of tools capable of detecting particular diagnostic proteins will become more efficient and less expensive. It is predicted that in the future, there will be widespread use of inexpensive rapid detection kits using small samples of blood or saliva and capable of detecting a wide range of proteins which may include microbial products, antibodies and host proteins. Micro-/nano-electromechanical system sensors are being created to use saliva to monitor health status, disease onset and progression and treatment outcome using specific biomarkers (14). Although the determination of suitable biomarkers is currently an impediment to this approach, progress will certainly be made. It is possible for example that analysis of proline-rich proteins in saliva may be of use in diagnosis of caries susceptibility. Elucidation of the human proteome will also enable the development of novel pharmaceuticals. If the structure of a gene product is known, a drug can be rationally constructed to target this. This concept has resulted in structure-based drug designs for the treatment of HIV (15).
Although advances in genomics and proteomics have great potential to impact on dentistry, as yet these have in general not led to great changes in current diagnostic and treatment techniques. Dental materials however have changed vastly and rapidly and have had an enormous impact on the everyday practice of dentistry. Dental implants are an area of obvious importance in dental practice and their success is dependent upon the use of biomaterials including titanium and bioceramics (16). However, it is however increasingly recognized that research into the molecular basis of bone healing, including the action of regulatory proteins is essential to maximize the future success of dental implants. As a direct result of this research, the effectiveness of the delivery of biomolecules such as bone morphogenic proteins, collagen and TGF-β is being assessed.
Impact of biotechnology on research
A large range of research tools has been provided by biotechnological advances. One of the earliest and most widely used of these is PCR. This is used to amplify specific DNA fragments in order to detect particular proteins. This detection can also be quantitative (real-time PCR). Gene expression analysis or microarrays, measure mRNA levels. Unique DNA sequences (probes) are biochemically fixed to a glass slide. The easily degraded mRNA is converted to the more stable complementary DNA (cDNA) which can then be hybridized to the probes on the slide, stained and read. This technique has been very expensive although with increased production efficiency costs are becoming more reasonable. Dealing with the vast amounts of data produced is extremely difficult and requires sophisticated computer analysis and expertise. Protein expression analysis involving protein microarrays and high-throughput mass spectrometry is also used. The enormous task of decoding genomes and proteomes makes collaboration and dissemination of results essential. Public genome and proteome databases therefore exist to share information amongst the scientific community. The elucidation of the mouse genome has resulted in a wide range of transgene and knockout mouse models for use in research.
As outlined earlier, the impact of biotechnology on research has been profound. Tools to examine the genetic code and its resultant products have forever changed the way we understand biological systems. Naturally, the questions that can now be asked are greatly different and this has led to remarkable progress in all areas of human health research. In addition to good quality basic research, translational research is required which enables the basic science to find a clinical application. There is a common perception that basic dental research and clinical practice do not overlap (17). Haffajee and Socransky (18) lament the decline in numbers of researchers with a clinical and scientific background who are qualified and willing to take on this role in periodontal research. Barriers include extensive training required, low salaries, increasing administrative requirements, lack of research funds and the difficulties of carrying out clinical studies. The importance of this role for the future advancement of dental research must be addressed at the level of the profession, the research institution and the funding bodies. Multidisciplinary teams are essential.
The tools which have enabled such rapid progress have also resulted in the production of large amounts of complex data. It must be remembered that the quality of research outcomes and their potential to add significant findings to our existing knowledge base is limited by the quality of the research question originally posed. A caution has been raised to avoid producing ‘vast arrays of information about virtually nothing – that is, more information about fewer and fewer samples’ (18). Our research must be driven ultimately by the oral health needs of our patients and communities.
Impact of biotechnology on dental education
As dental education must be research led, or at least research informed, it is essential that dental curricula be developed to reflect the importance of this emerging field in the way dentistry is understood, practiced and researched. Current developments are changing the way that dentists diagnose, treat and prevent disease. Additionally, the oral health of an individual is increasingly understood to be closely related to overall health. Students must therefore have knowledge of the molecular basis of genetics, techniques of genomics and proteomics and their application in current medical and dental practice.
Traditionally, basic sciences in dentistry have been seen, by students, simply as obstacles which must be passed to enter the clinical programme. In the clinics, science may be perceived as having little relevance and therefore not well used to advance patient care (19). This culture is likely to produce highly technically competent graduates who will become obsolete within the time of their career. To integrate biomedicine and biotechnology successfully throughout dental curricula, research-led teaching must occur. Research is and should be a fundamental activity of universities such that the best teaching cannot occur in an environment lacking active and enthusiastic research and scholarship. Research experience is a crucial aspect of dental education. Current ethics restrictions are proving a barrier to undergraduate research opportunities and so this experience may be limited to writing literature reviews and grants or ethics proposals.
Dental academics must embrace this new technology and use the information and techniques available to ensure that dental research remains competitive in terms of contributing to the scientific knowledge base and also of receiving funding for research. Work in this area cannot occur without the appropriate technical expertise and the use of very expensive specialized equipment. It is not likely to be feasible therefore for individual dental schools to conduct such studies without active collaboration with other teams which may be based in medicine or science.
Lantz and Chaves (20) offer four guiding principles for the adaptation of dental curricula to encompass biotechnological advances:
1The biosciences must be taught at a level that allows clinicians to apply emerging technologies over their lifetime.
2They must be learned in context and tied to problems in healthcare.
3Students should not only learn science concepts but use the methods of science as a means for developing critical thinking skills and clinical judgement.
4Learning of professional behaviours and interpersonal skills is embedded in learning of biosciences by, for example, use of problem-based learning (including peer evaluation and reflective self-evaluation).
Students must have a working knowledge of epidemiology, bioinformatics, molecular medicine and dentistry and bioengineering if they are to be able to adopt new evidence-based preventive strategies, diagnostics and therapeutics (2). These subjects should not be studied in isolation if we intend students to accept and utilize this knowledge in their practice and understanding of clinical dentistry. This requires expansion and integration of these areas throughout the curriculum to ensure that students perceive them to be essential to their future practice. Teaching and learning modes should focus on problem solving. The simple transmission of knowledge in this field is doomed to failure. This is first because students will fail to see the clinical relevance, and learning will be superficial and soon forgotten. Second, information in this area is soon outdated so students need to understand the basics so that they can keep updated in the future. Laboratory experiences would be valuable in achieving these aims as they promote critical thinking and hands-on (experiential) learning which is complementary to clinical practice. Familiarity with the use of the research literature is required to facilitate the practice of evidence-based dentistry postgraduation.
Baum (21) suggests that for dental students the process of critical thinking is the key, rather than learning content which could soon become outdated. He believes that a critical impediment however, is that science and scientific enquiry are under-valued by dental school administrators, teachers and the profession. Similarly, Iacopino (22) stresses the need for dental schools to ‘infuse ‘new science’ and evidence-based critical appraisal skills into their students’ educational experiences’ if their respected professional status is to be maintained. He sees challenges to include the overcrowded curriculum and too few teachers with an adequate background in both clinical and basic sciences to support this new curriculum.
The practice of dentistry has, and will continue to, change radically so graduates must be prepared to respond. Dental schools must therefore produce more scientifically oriented practitioners who are able to critically evaluate and take on new innovations. Further, they must equip students with the skills to continue learning throughout their professional life. Information literacy is critical for this and is an area which should be specifically addressed. There is also a largely unmet need for appropriate continuing education courses that enable practitioners to keep abreast of developments in biotechnology.
Information literacy enables individuals to ‘recognize when information is needed and have the ability to locate, evaluate and use effectively the needed information’ (23). It is therefore a means of dealing with the ‘data smog’ created by the overwhelming and increasing abundance of information confronting us all (24). There is an obvious requirement for students to be information literate to cope with tasks as an undergraduate. Perhaps more importantly however, there is a need for these skills past graduation. Individuals must embrace information literacy, not just as a set of tools to accomplish tasks, but as a way of thinking and performing in every aspect of professional life.
Students who have developed information literacy skills are equipped to take the fullest advantage of problem-based learning. It follows that these students will also be well placed to solve problems in practice as new graduates. Elmborg (25) argues that learning should be redefined as the ‘humanistic process of engaging and solving significant problems in the world’ and information as ‘the raw material students use to solve these problems and to create their own understandings and identities’. Information literacy is therefore the ability to utilize information for learning and its development should be thoughtfully integrated throughout the curriculum. This will enable our students to succeed academically, professionally and throughout life.
Facing the challenges – present and future
We have at our disposal now many techniques and technologies which enable us to know more about our patients and their disease than ever before. The increasing availability of tests for genetic susceptibility to a range of serious diseases raises issues regarding the confidentiality for individuals positive for high-risk genes. Ethical considerations must go hand in hand with scientific advancement. In the current context, health insurance companies and employers may discriminate against individuals identified as being at high risk. Regulations are therefore required to prevent problems in this area. Tests must also ensure their validity and take into account the effect of other factors which may impact on the real risk of disease occurring. Also if there is no current treatment to reduce the risk of a susceptible person developing the disease, then is there value in diagnosis? The ability to screen embryos for genetic diseases raises further ethical issues.
Government bodies need to adapt to the rapid pace of change and in addition to ethical and social issues, there are regulatory issues that will need to be addressed. Rapid advances in drug design for example, will be slowed if drug approval procedures fail to keep pace. There is an ethical requirement for the benefits of biomedicine to be made available to developing countries, to deal with their current problems of infectious diseases including tuberculosis, malaria and HIV. It is incumbent upon biotechnology as an industry to redirect some of the enormous profits gained from these advances to focus on the need for improving the health of the poorer populations of the world. Better, cheaper diagnostics to treat disease earlier with better targeted treatments would be a worthy goal (26).
Clinicians will increasingly be required to apply molecular-based diagnostic and treatment modalities and unless students have learnt and practised the skills of scientific thinking and critical evaluation, there is a temptation to look to commercially provided documentation of the efficacy of new technologies. Graduates must have the skills and confidence to evaluate the effectiveness and suitability of new clinical developments. This is in addition to the traditionally recognized skills and knowledge required to practice dentistry competently. It would seem, therefore, that dental curricula are in grave danger of becoming ever more overloaded. It should not be expected that our dental graduates will be molecular geneticists, however it should be expected that they are able to apply appropriately new technologies as they become available.
A willingness to share intellectual resources should be encouraged. In general, although development of new technologies is expensive, the end product should be affordable and pertinent to developing countries. Further efforts should be made to incorporate both educators and researchers from economically disadvantaged areas into established research teams in developed countries. This would result in a transfer of expertise to less advantaged areas. It is recognized that undeveloped areas exist even in developed countries throughout the world, and in this context new technologies should be available to these communities. To redress the ever-widening gap between more developed and less developed countries, in terms of research and development opportunities, a virtual university could be considered under the auspices of the International Federation of Dental Educators and Associations (IFDEA). Governance of such a university would need to be agreed upon.
Conclusions and recommendations
Currently, molecular biosciences and technologies are emerging fields in dentistry. Nevertheless, it is clear that an understanding of molecular biosciences will underpin modern dentistry at both the individual and community level. There is no doubt that current and future developments in molecular biosciences and technologies will have a major impact on the practice of dentistry. They will improve our ability to diagnose and assess risk for oral and systemic diseases more accurately. Gene therapy, tissue engineering and novel drug developments will dramatically change patient care. The major challenges we face are how to transfer research discoveries into improved oral health globally and how to incorporate this knowledge base into dental curricula so that clinicians will be able to deliver the best possible care to their patients and communities.
A number of recommendations can therefore be put forward which could provide direction for the future of dental education and enable it to take the fullest advantage of the remarkable developments occurring in the field of molecular biosciences. The development of biomedicine/biotechnology as a stream in the dental undergraduate programme which encompasses molecular genetics, tissue engineering, clinical applications and multidisciplinary approaches to health is the key to this aim. The challenge, however, is to make this relevant, timely and to avoid overloading the curriculum. The Mission Statement of IFDEA is to disseminate relevant information to dental educators on a global basis by creation of a global network of dental educators. The establishment of this network will greatly facilitate the development and successful implementation of such changes. Dental research using biotechnology as a tool rather than a focus should be encouraged. Successful research in this field requires collaboration and initiatives to increase funding. Industry partnerships may be one option to provide research funding and to facilitate practical applications of this research. Therefore, it is recommended that:
1Molecular biosciences and technologies should be taught and learnt so as to be used ethically and appropriately, in a clinically relevant setting by all members of the dental team, e.g. salivary diagnostics and pharmacogenetics.
2Molecular biosciences and technologies should be integrated throughout curricula so as to lead to their utilization in the diagnosis, treatment and prevention of oral diseases.
3Continuing professional development in the molecular biosciences and technologies should be offered to faculty/staff so as to facilitate successful transfer of new knowledge to students for the ultimate benefit of patients.
4Information literacy should be taught so as to ensure students know how to access, evaluate and apply new knowledge in the molecular biosciences and technologies for the benefit of patients.
5Advances in molecular biosciences and technologies as they apply to oral health should be provided to the highest risk populations at reasonable cost so as to help contribute to the alleviation of suffering throughout the world.