Inside Dentistry
June 2012
Volume 8, Issue 6

John D.B. Featherstone, MSc, PhD

This dental scientist from New Zealand became dean of a leading US dental school and major proponent of caries management reform.

Interview by David C. Alexander, BDS, MSc, DDPH

INSIDE DENTISTRY (ID): What took you into chemistry, then onto the health sciences, specifically oral health and caries?

JOHN D. B. FEATHERSTONE (JDBF): I grew up in a small town in New Zealand, where most people didn’t go to university. I was encouraged by my high school chemistry teacher to apply for a Lever Brothers scholarship, which funded me through undergraduate school, where I was urged by a professor to continue my education for what he correctly predicted to be a successful career in academics. However, after graduation, I went directly to work for Lever Brothers as a management trainee, and a chemist. I went on to work in the laboratory of a small pharmaceutical company where I became fascinated with pharmaceutical products. After a few years I moved to England with my family, where I worked as production manager in a pharmaceutical company and decided to return to university to continue my education. This led to the decision to do a PhD back in New Zealand where I was awarded a Medical Research Council (similar to NIH in the US) scholarship to conduct research on the chemistry of dental decay…and that was it! One thing led to another and I went on to the Eastman Dental Center, and University of Rochester in Rochester, New York.

ID: How and why did you develop an interest in academic leadership and administration?

JDBF: I didn’t actively pursue it; it just happened. I would say many of the turns in my career have been accidental, in terms of going from one thing to another and recognizing opportunities. Like most successful people, I’ve had a handful of mentors over the years who have helped me in one way or another to get my feet on the ground or to just focus me in. Among them was a fantastic one who knew nothing about dentistry, but he sure knew science—how to manage it and how to keep it relevant—and that had a big influence on how I’ve handled my own career.

That said, I had always been a leader throughout school and my early career, but didn’t consider becoming an academic leader until my department chair in the Eastman Dental Center left. It was then that I decided to take charge of my destiny, so I applied for the job and got it. After 15 years in Rochester I moved to University of California San Francisco, where I essentially fell into the position of chair of the Department of Preventive and Restorative Dental Sciences, which I held for 9 years.

Likewise, when the chancellor persuaded me to become interim dean, then dean, at UCSF, I recognized it as an opportunity to make much-needed changes. When I accepted, I told him, “I have no interest in being a caretaker. I’m going to start fixing things,” which is exactly what we did. I immediately started gathering around me a new team and we started making major changes, including the addition of digital radiography, renovations, and restructuring the way that we were doing our clinical dentistry. This has been to the benefit of the students, who now have many more clinical opportunities and patient visits than previously, but it has also been good for the bottom line. In spite of severe budget cuts, we were able to make these changes while also strengthening and continuing to give strong support to the research enterprise.

ID: What do you consider the greatest challenges faced by dental schools, and how can they be overcome?

JDBF: I can only speak for deans in the United States, but I say the biggest challenge—certainly among the public universities—is the reduction in public money, which has been cut by almost 30% in the last 4 years. Even increasing student fees and tuition doesn’t come close to balancing that deficit. Therefore, the big challenges are to maintain the level of excellence while at the same time reducing expenses and increasing revenue. It’s no different than managing any business; if you just cut back, you’ll kill the enterprise.

In dealing with these challenges, I’ve been very fortunate in having fantastic faculty, students, and staff, who have all pulled together in these troubled times, and I think we’ve come out stronger as a result. We’ve had a lot of input and ideas and we’ve been able to put them into practice. Thanks to the advent of electronic replacement of books, we have been able to turn an entire floor of the library into an interdisciplinary learning center, which includes a simulation facility for an operating room, with library tables turned into dental chairs.

We are considering ways to be more efficient and take advantage of new technology and ways of learning. For example, we can unify some of the teaching across the country by taking advantage of the movement toward online teaching. Instead of training our own faculty to teach new subjects, we can offer our students online courses in the biomedical sciences developed and put together into videos that are delivered by the best people in the country. We can also find other ways to embrace new technology being used for other purposes such as tablets, like iPads, to teach even better.

ID: What sort of developments would you like to see in the next 5 to 10 years in dental education and how can they be put into motion?

JDBF: One of the biggest changes I would like to see universally adopted is a whole change in philosophy in terms of caries risk assessment and management. It all needs to be a continuum starting with risk assessment and embracing therapy before restorative work. In fact, one of the first things I did as a department chair here is to eliminate preventive clinics and to roll it all into one continuum.

This is a huge change, a paradigm shift, which we and several schools across the country have adopted and are still tweaking. I would also like to see that happen in the periodontal area.

These efforts have thus far been hindered by resistance to change, traditional teaching, and inertia, in contrast to the medical profession, which has already made the change to prevention and intervention. We’ve got enough information to put it into practice, as we did 8 years ago here at UCSF, with caries management. If we could take the long-term view and implement prevention and the whole idea of minimally invasive dentistry across the board—instead of just paying lip service—it would save the country and the insurance companies millions of dollars.

We also need to embrace new technologies, moving forward with laser technology, the technology relating to implants, and CAD/CAM.

ID: What approaches are being taken to develop other essential attributes of becoming a member of the dental profession?

JDBF: About 10 years ago now, we introduced a totally new curriculum, which runs in five thematic streams and cuts right across departments. These mega-courses are taught by people from several departments, starting with the biomedical sciences, which comprise the bulk of the first-year curriculum. From the first day, students step into the preventive and restorative laboratory, where they first start learning about prevention; then the next week, they start learning about restorations. At the same time, they are learning anatomy and basic science and following the whole picture through in tandem with being taught by some of the best leaders in science in the world. In this way, the clinical education is underpinned by an evidence-based scientific foundation, with some of that evidence having been produced right here in our own school.

What is absolutely essential is that dental schools focus basic science teaching on what the students really need to know now, that is, the functions of the body as a whole and how the craniofacial complex fits with the rest of the body. They need to know chemistry, they need to know biomaterials, and they need to have dental sciences, which is the bridge between biomedical sciences and patient-centered care.

Our aim is to turn out students who will be able to look critically at the literature, look critically at the science, at the thousands of things coming at them, and be able to not only understand but embrace what is the best of the clinically new information and research, rather than follow a cookbook recipe of A+B=C that will be obsolete in clinical practice in 10 years.

ID: Where do you stand on the hotly debated topic about the need for the research and the scientific experience in the pre-doctoral curriculum?

JDBF: We do not expect and we do not insist on every student participating in research, although the opportunities are there; we have a summer research program at the end of the first year, which is very competitive, and, of course, we have postgraduate students. There are students who don’t want to participate. They want to get on, complete their dental school education, and get out into the world of everyday dentistry. However, these students are in an atmosphere where the entire curriculum is underpinned by science, so they can’t help but soak up some of it.

ID: So, how can busy practitioners keep abreast of these changes in science and technology?

JDBF: I think continuing education needs to embrace even more than it does the teaching of new technology, new thoughts, and it should encourage our practitioners to really be part of it. What they really need—in my opinion—is summary information, and that’s the kind of thing they can get from continuing education courses. Also, there’s a tremendous possibility of having digital applications in which practices can download a 30-minute summary of some aspect of dentistry—science, new techniques—to view while on a plane, while on vacation, or instead of watching television. Most clinicians want to understand what’s going on in the profession; and those who don’t aren’t likely to read CE materials anyhow.

ID: How does personalized healthcare relate to the prevention and management of dental caries?

JDBF:Personalized oral healthcare starts with caries risk assessment, but its success depends on overcoming the continuing problem of patient compliance with the necessary treatments indicated for their risk level. Whether you call it CAMBRA or something else, we need to start with risk assessment to split people into risk levels—low, moderate, high, and extreme. Once risk is determined, the next step is to deliver the therapy that will help them bring their risk level down from extreme to high, high to moderate, and moderate to low. Next is the restorative treatment plan, which has traditionally been drilling and filling, placing crowns, implants. It shouldn’t be a surprise that those who most enthusiastically embrace the CAMBRA principles are the prosthodontists, whose work must be done repeatedly when the fundamental disease process is not brought under control.

We have the technology, but there’s a limit to what we can do in the dental chair. The problem with preventive measures continues to be getting people to buy into them.

ID: What needs to be done to bring other forces to bear upon the disease?

JDBF: As a profession, we need to change our philosophy from being a procedure-driven profession to one that focuses on prevention, which demands changes in how patients and doctors interact. This requires a whole different set of skills, including effective patient education and behavior management to encourage compliance. It also requires the support of the insurance companies, which are willing but not yet ready to modify reimbursement policies in keeping with these needed changes.

Perhaps someday technology will offer a slow-release antibacterial device to insert in the mouth, but that won’t solve the problem entirely. Caries is not a disease like TB with one antibacterial that goes against one bacterial species. With caries, there are multiple species; we have to modify the activity of the biofilm rather than one or two species within the biofilm.

In the meantime, we spend a couple of billion dollars a year on dental treatment for a disease that could be headed off at the pass even with existing technologies—if only we would use them.

ID: What major changes have you experienced during your career? What would you say have been the notable breakthroughs? Where could the next breakthroughs come from in terms of dental caries?

JDBF: One of the biggest breakthroughs in dentistry—one that occurred while I was still in the industry world—was the advent of fluoridated water in many parts of world as well as fluoride toothpaste, which reduced decay but didn’t solve the problem to the extent that it was hoped.

Part of what happened during that time was a tremendous proliferation of science, which, in a small way, I contributed to with colleagues, in determining just how fluoride worked. Recognizing that its effect was primarily topical—not systemic—we switched our focus to how to apply therapy. It made a huge difference when we started applying therapy and higher levels of fluoride in a targeted fashion. This led to the development or resurrection of products that could be used in the dental office and were proven by clinical trials to be designed to deliver fluoride better. Another enormous breakthrough—the widespread recognition that caries was a bacterially generated disease—was actually reported on in the 1930s by Basil G. Bibby, DMD, PhD, of the University of Rochester.

So, within the past 15 years, there have been great strides in understanding biofilm and ways of dealing with it. We also saw the failure of efforts to develop a caries vaccine, which helped us understand the caries process. Had we understood the process in the first place, we would have never considered developing a vaccine.

As a result, I think we have a very thorough understanding of the whole caries process now and we’re homing in on solving the problem. While, theoretically, we could eradicate caries now with the technology we’ve got, these efforts are hindered by the need for compliance by individuals. I believe the real key to the elimination of caries is having therapies that can be applied without the necessity of people complying in their daily lives. I think it can be done, but it’s not going to happen in the next 10 years.

In the future there may be therapies such as targeted slow-released antibacterials that could be placed in the mouth for a period of weeks and targeted re-mineralizing agents enhancing fluoride. I think the potential of probiotics to modify biofilm is great, but not the ones that are now available. Some of these strides are based on research from our laboratories here, which we hope will lead to breakthroughs in the caries treatment for the future.

About Dr. Featherstone

John Featherstone, MSc, PhD, is a professor of Preventive and Restorative Dental Sciences at the University of California, San Francisco (UCSF) and Dean of the School of Dentistry. He earned his MSc in physical chemistry from the University of Manchester (UK) and a PhD in chemistry from the University of Wellington (New Zealand).

His research over the past 37 years has covered several aspects of cariology, including fluoride mechanisms of action, caries risk assessment, de- and re-mineralization of the teeth, apatite chemistry, salivary dysfunction, caries (tooth decay) prevention, and laser effects on dental hard tissues with emphasis on caries prevention and early caries removal. He is currently active in implementing caries management by risk assessment in several dental schools across the nation.

He has won numerous national and international awards, including the International Association for Dental Research distinguished scientist award for research in dental caries (2000), the Zsolnai Prize from the European Caries Research Organization (2002) for his lifelong contributions to caries research, the “Ericsson Prize in Preventive Dentistry” by the Swedish Patent Fund (2002), and the Norton Ross Award for excellence in clinical research from the American Dental Association (2007). He has published over 250 manuscripts and book chapters, and he is an honorary Fellow of The American College of Dentists.

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