The Future of Prosthodontics An Indian Perspective Prosthodontics as a specialty can stake its claim as one of oldest dental specialties and has a long history of innovation and adaptability. There have been several landmarks in the development times to the present and as I indulge mu mind, speculating on what the future trends in this specialty could be or what the future beholds for us, I am struck by the cliché ‘the future often arrives faster than expected’ and it makes me realize that, it easier to create of discover the future than to predict it. If we consider the immediate past or look into the current situation in the rural areas of our country or the world over, we could safely conclude that prosthodontic procedures dominate dentistry as teeth are extracted on a routine basis and removable complete denture prosthesis are fabricated for patients a dime a dozen, when natural teeth could have been saved by preventive dental procedures. But with the increase in life expectancy and better oral hygiene awareness of the general population, fixed implants and removable partial prosthodontics are now a major part of prosthetic dentistry. According to Dr. Gorden J. Christensen, this trend will continue as people live longer to retain even more natural teeth and have greater desire for more elective restorative conservative and esthetic procedures. The Australian national oral health survey and the ABS special supplementary survey in dental health, have estimated rapid decline in the incidence of fully edentulous patients from 60 to 80% in 1979, to a projected 8 to 18% in the year 2019 for the age group of 60 to 75 years. A WHO study on oral health way back in 1998 has put the percentage of edentulous population of Italy, Switzerland and Austria to below 14% for the same age group. All these are indicators for the changing trends the world over, especially in the developed countries and even though these figures are too farfetched for the general Indian population, it could be foreseen in the near or distant future in our country too, where in a steady decline in edentulous patients are a possibility. In this context, it could be said that in some of the developed countries in the world, a fully edentulous patient could be as hard to spot as a dinosaur. However, the prosthodontics of today is a different genus from that which existed in the past. The practice of dentistry has shifted from treating young people to treating mature adults. The complex and exciting field of Prosthodontics is one of the nine recognized specialties in dentistry, but it is a fact that it is one of the most battered specialties as most of the routine prosthodontic procedures are accomplished by general practitioners which cannot be abridged by any means in the current scenario. We, Prosthodontists, are considered a generous group. It is said in some scared scriptures that “the future belongs to the who shares” Ours is a specialist who has probably never shied away from sharing knowledge t the general dentist, unlike many others who consider that theirs should be a closely guarded secret. The Prosthodontist has significant in-depth background in the complex technical and biological aspects of fixed prosthodontics or removable prosthodontics, where there is a general lack of understanding among the general dentists on the need for planning removable partial prosthesis including clasp designs, semi precision and precision attachments, frame works, denture base and occlusion. A Prosthodontist should be capable of providing clinical support, treatment planning and educational information to practitioners so as to minimize or nullify the damages that may be inflicted by unprofessional hands. This could be one of the future roles of Prosthodontists as I see it. Implants – the future? Dental science as it stands today looks into Dental Implants with a great degree of hope for the future. The increasing and fast paced progress in this field along with the rapid progress made in the area of radio imaging and diagnosis had made implants a predictable and viable restorative option. This complex area of prosthodontics has made a major stride in the past few years especially in its designs and surface treatments and newer research in the fields of nano-technology, translation research, bone growth factors and computer-guided surgery has made this field more exciting and predictable for the future. With a trend in an increasing awareness on implant dentistry the world over in general and India in particular, the urban prosthodontic practice will see an immediate shift in more implant related practice with a relative decline in contemporary crown and bridge prosthodontics. A Prosthodontist could find himself being implant illiterate if he is not in tune with this emerging and established field of dentistry which actually requires stilled prosthodontic resources from the planning stage to the restoration phase. I predict that implant prosthodontics will continue to increase in need and demand, become more refined clinically, and become more and more a routine part of prosthodontic practices. But is it the future? One can never say. With the major strides and advances in stem cell research and bio engineering the days of a bio engineered tooth replacement may not be far away. A Few Prosthodontic “Specialties” Looking to the future, I can only see a few areas of prosthodontics that we could hold close to our hearts as a specialty. Maxillofacial prosthodontics is one area which requires a skilled Prosthodontist to plan, design and execute prosthesis. The complicated impression procedures and the subsequent laboratory procedures which requires tremendous skill makes this an area which could remain a prosthodontic specialty for the future too. The technological advancement for the future in this field could include rapid prototyping in generating or constructing physical objects using additive manufacturing technology or construction of a wax pattern of a missing body part using ‘selective laser sintering process’. A Prosthodontist could also find himself getting involved more on the disorders of the stomatognathic system especially TMJ disorders and correcting occlusal discrepancies, in his pursuit of establishing a specialized area for himself in the future. You could also find him mastering some techniques on psychology and patient management as he need to address the stress factors of the new age patients who approach him for the above said reasons. Removable partial dental prosthodontics could partly remain a prosthodontic bastion as a majority of the general practitioners do not dare to tread this area for want of in-depth knowledge viz. surveying, designing and other reasons as mentioned earlier in this article. The future of prosthodontics as I perceive it could also be in Lasers. Lasers as it gets evolved could find its application more and more in the field of prosthodontics with increasing number of new age Prosthodontists embracing it as their specialty in the future. For example. A. In Fixed prosthodontics, lasers could be routinely used 1. To treat dentinal hypersensitivity (HE Ne Lasers, CO2 lasers, Nd YAD lasers etc.) 2. Tissue management (crown lengthening) 3. Using hydrokinetic technology (Er Cr YSGG laser) even crown preparation could be a possibility in the future in the hands of a highly skilled Prosthodontist. B. In Complete Denture Prosthodontics, laser could find application in 1. “Additive prototyping” and Laser Rapid Forming (LRF) for manufacturing a complete titanium denture base. 2. Study of complete denture occlusion by three-dimensional technique, where after fabrication of new dentures the occlusion can be examined and studied with the help of laser scanner technique and three-dimensional reconstruction. The relationship between the parameters of balanced occlusion can also be analyzed. C. In Removable partial dentures. In Laser welding – one of the modern methods in removable partial denture repairs uses the pulsed laser with relative low average out power. This is known as a precise and rapid joining method, but its success depends on the control of many parameters. D. In Implant dentistry 1. For sterilization of the socket: In immediate implant dentistry after extraction of tooth, without any infection, socket can be sterilized immediately. 2. In case of peri-implantitis: Since the laser does not transmit damaging heat, it can be utilized to vaporize any granulation tissue as well as clean the implant surface in peri-implantitis cases. This procedure eliminates the acute state of peri-implantitis, resulting in positive GTR, and allowing the patient extended use of the implant. 3. To debride the implant surface: Development of a laser system operating at 2780 nm and using an ablative hydrokinetic process offers the possibility for more efficient decontamination and debridement. Laser ablation using the Er., Cr: YSGG laser is highly efficient at removing potential contaminants on the roughened implant surface while demonstrating no effects on the titanium substrate. Lasers could also have extensive application in the field of maxillofacial prosthodontics as mentioned earlier in this article. “Corrective Prosthodontist” Above all these, many Prosthodontists currently and in the future may find themselves specializing in “CORRECTIVE PROSTHODONTICS” as many of them would be called in to correct or restore many an ill fitting and unscientifically delivered prosthesis by an increasing number of unskilled and untrained general practitioners. This probably could be a bigger challenge and will test the skills of many a Prosthodontist in the future. Investing in the future generation As an academician, I would predict a bright future for our specialty if we invest wisely in our younger and future generation of Prosthodontists . There should be a drastic shift in the way we teach prosthodontics to the new generation, changing with time and technology, with an emphasis on newer and novel methodologies and equipment made available to our post graduates. More and more knowledge up gradation programs have to devised and conducted by different institutes and societies so that we are not caught or engulfed in a time warp. The Indian Prosthodontic Society should collaborate with different prosthodontic societies the world over and should have a forum where in exchange of ideas and sharing of knowledge can happen for which e-learning and the wide use of web based session could be utilized. There will be no dearth of clinical situations where in a Prosthodontists skill and knowledge needs o be applied or requested for. For this we need to be competent and upgraded, we should be a concrete and conscious effort from each and every one of us to improve the public and professional perception of the specialty of Prosthodontics. We should bludgeon our way into being leaders and spokespersons of our profession and should fine tune ourselves in being the best ambassadors of our specialty. Go Interdisciplinary Prosthodontics, as I foresee in the future will see drastic change in its approach to clinical situations where in a holistic view will be seen as the need of the hour. This will be necessary in order to cater to a different sect of demanding and educated patients of tomorrow or the future. Information on any treatment option for a patient is now in his or her fingertips. We should expect a patient walking in armed with all the details he or she requires before you even open your mouth to explain. We should train ourselves to be competent enough to cater to the demands and expectations of these patients to the future to be working in a team as a core restorative group which will positively include a periodontist and an endodontist along with a Prosthodontist and an implantologist forming the hub of restorative dentistry. God forbid, we could even find ourselves merged as a single specialty in the near future. The future is what we make of it. The future of Prosthodontics resides nowhere else but, I believe, in two areas, IN OUR MINDS and IN OUR HANDS. Technology and science will help us in being new age Prosthodontists of tomorrow; we could even call ourselves ‘Digital Prosthodontists’. Yes, prosthodontics has always been ‘digital as there is no successful prosthodontics without the use of digits or fingers, we should never forget that the skill we show with our digits and keeping abreast with the fast paced knowledge or information highway is of primary significance in moving forward to the future, for your heart may conceive an idea and your head decides vainly, if the hands are not prompt to execute a plan. Which highly points to a practice and performance oriented prosthodontic training inculcating up-to date and modern conceptual based education with firm roots on the basics in prosthodontic knowledge for the generation of future Prosthodontists. My Parting Remark For a Prosthodontist in India or anywhere else, there will be no death of clinical situations or materials where in a Prosthodontist’s skill and knowledge need to be applied or requested for. For this we need to be competent and upgraded, we need to market ourselves diligently. There should be a concrete and conscious effort from each and everyone of us to improve the public and professional perception of the specialty of Prosthodontics. If I may condense these thought processes to a few consensus statements. There is a need to increase patient advocacy and awareness efforts in the specialty of prosthodontics for the future. There is a need to transform and keep growing., keeping abreast to newer technological advancements in the field of prosthodontics within the next few years. The number of institution based advanced prosthodontic post graduate training programs need to grow and revamped. The existing Prosthodontist community should be exposed to more and more of continuing information and upgradation programmes, so that we change our mindset progressively according to changing times. Science and technology will be the driving forces and be partnered in these transformational growths. The culture of prosthodontics needs to change to leading the specialties and educational environment in restorative, implant, esthetic and reconstructive dentistry. “I never worry about the future”, said Albert Einstein, when he was asked about predictions for the future, “it comes soon enough”. Waiting for the future to arrive is like sitting in a time machine and going backwards, walk towards and prepare for the future, face it head on, for the future of prosthodontics in our country and the world over is nothing but BRIGHT. “The views expressed in this article are purely those of the author and is in no way intended to detour or impair the sentiments of the peers in any way, if any”.
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