Is dentistry ready to get more personal?

The next paradigm for dental healthcare will be more personalized care, and scientific advances such as genomics and oral biomarkers will play a key role in better addressing head and neck cancer, orofacial pain, and oral infectious diseases, according to an article in the Journal of Dental Research (JDR, May 20, 2013).

While some practitioners may take offense at the notion because they already provide personalized care, others -- such as study co-author Martha Somerman, DDS, PhD, director of the National Institute of Dental and Craniofacial Research (NIDCR) -- contend that advances in science and technology are making it possible to enhance patient care by getting even more personal.

"Dentists and physicians have long recognized variations between and among patients and have customized care based on each individual patient's health history, environment, and behavior," the researchers wrote. "However, the sequencing of the human genome in 2003 and breakthroughs in regenerative medicine, imaging, and computer science redefined 'personalized medicine' as clinical care that takes advantage of new molecular tools."

As a result, "now is the time for oral health professionals, educators, students, researchers, and patients to engage fully in preparations for the arrival of personalized medicine as a means to provide quality, customized, and effective oral healthcare for all," they wrote.

Government support

Over the past decade, the U.S. government has invested heavily in projects designed to bridge the gap between genomics research and targeted clinical therapies that will be relevant to the dental field, the study authors noted.

"Most oral, dental, and craniofacial diseases and disorders, such as dental caries, periodontal disease, oral and pharyngeal cancers, chronic orofacial pain, and cleft lip/cleft palate arise from a complex interaction of genetic, biological, behavioral, and environmental factors," they wrote. "As our understanding of disease pathways, genomic interactions, and novel biomarkers of oral conditions continues to increase, so does the possibility of using high-throughput 'omics' approaches to assess risk, prevent disease, and guide treatment."

For example, the Oral Cancer Genome Project, funded by the NIDCR, is using techniques such as high-throughput exome sequencing to define the genetic changes that drive the development of head and neck squamous cell cancer. Related research has confirmed that HNSCC tumors associated with the human papillomavirus (HPV) have a different genetic profile from tumors in patients with a history of tobacco use. And several approaches based on protein expression and nucleic acid analysis show promise in more accurately predicting which patients are at risk of oral cancer recurrence.

Next-generation pain management

Another area in which NIDCR funding is helping researchers make new and important inroads is the management of acute and chronic orofacial pain.

For example, the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study is "the most comprehensive analysis to date of risk factors involved in the onset of orofacial pain conditions," according to the JDR authors. The OPPERA study combines genetic, psychosocial, and pain amplification data to help identify a subset of variables that clinicians could incorporate into health history questionnaires.

"While these results are not yet ready for clinical adoption, they provide important clues that dentists and other healthcare providers might use ... to identify individuals most susceptible to TMD [temporomandibular] and related chronic pain conditions," Dr. Somerman and her colleagues wrote.

Another area in which exciting advances are being made is in the management of oral infectious diseases, thanks to projects such as the Human Microbiome Project, a National Institutes of Health-funded consortium of nearly 80 universities and institutions.

For example, researchers have now identified genome sequences of several oral pathogens implicated in caries and periodontal diseases. As a result, small molecules could be developed that block or weaken enzymes that enable bacteria associated with caries to form a biofilm or attach to a tooth's surface, they noted. In addition, advances in imaging have led to better understanding of oral biofilm formation, organization, and composition.

"We can envision that, with advances in these and other technologies, dentists will be able to noninvasively visualize the microbial communications in an individual's mouth, guiding real-time diagnosis and treatment decisions," the JDR authors wrote.

Challenges remain

Perhaps the most advanced research to date has involved oral biomarkers. Numerous studies have demonstrated the presence, in saliva and oral tissues, of disease-related proteins and RNAs for oral cancers, cardiovascular disease, Sjögren's syndrome, connective tissue disorders, and periodontal diseases, and shown the potential for these and other biomarkers to improve pre-emptive care and create more precise therapeutic approaches.

However, while biomarkers and other genomic tools hold great promise for oral healthcare, "implementation into clinical practice remains a lengthy and expensive enterprise," Dr. Somerman and her colleagues noted.

"One of the barriers that impedes the clinical integration of genomics applies equally to medicine and dentistry: the skepticism by providers and payers of the added value of genomics to improve patient care," they wrote. This issue has not been helped by the fact that there have been few studies designed to quantify clinical usefulness of genomic-based tools and techniques.

Even so, Dr. Somerman and her colleagues are optimistic about the future of personalized dentistry.

"Tremendous progress in many areas of dental research will undoubtedly accelerate personalized approaches and fill critical voids in our knowledge," they wrote. "The dental health profession must engage in dialogue focused on preparing the current and next generation of clinicians, educators, researchers, and the public for the transformation in healthcare that is already in progress and will continue to evolve rapidly."