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The Relevance of Research to the Clinician
COMMENTARY THE RELEVANCE OF RESEARCH TO THE CLINICIAN B e rtra m C o h en , DDS, London
Much has been said about the gulf that divides clinical practice from laboratory investigation, and both would benefit if it could be effectively bridged. An awareness of research activity could infuse additional interest into the day-today routine of practice and, from the opposite viewpoint, if clinical problems and difficulties were constantly brought to the awareness of laboratory workers their research would inevit ably benefit. There can be no doubt that the substantial advances made in the science o f den tal materials over the past decade are in no small part due to the collective insistence of dental practitioners seeking improvement in the materials available for restoring or replacing damaged dentitions. Problems o f a purely biological nature are of much less interest to most clinicians and it is in this area that laboratory scientists are most fre quently criticized for esotericism or irrelevancy. Nevertheless, the possibilities of advancing knowledge would be sorely limited if the justifi able demand for envisaging an application were to be extended still further to an insistence that research can take its inception only from at tempts at prevention or therapy. It would be akin to training long-distance runners by permit ting them to practice only the sprint over the last 50 yards to the tape. Clinicians who have no patience with reports of research on rats, or the interpretation o f electron micrographs, or at tempts to understand the minutiae of molecular biology are decrying the research worker for the toil he expends on long-distance training— because they can envisage no more than the final burst in the finishing straight. Collaboration between dentists and scientists from other disciplines is most likely to be fruit ful when they share a common language. To this 720 ■ JADA, Vol. 96, May 1978
end it is all-important that dental graduates should be encouraged to enter into the study of different basic sciences. Dentistry needs den tally qualified anatomists and physiologists, biochemists and pathologists, microbiologists and immunologists; dentists, that is, who have been prepared to study the subject in depth and not merely at an abbreviated level sometimes implied in the prefix “ oral.” The ideal situation is that in which teams of research workers include dental as well as non dental scientists. Dental graduates do not pos sess exclusive knowledge in regard to the teeth and their surrounding structures, but it is un realistic to believe that people who have not en dured day-to-day acquaintance with dental dis ease can share the depth of understanding pos sessed by those who have. The story o f the discovery o f anesthesia bears repetition to illustrate this point. It happened that in 1844 a chemist named Colton was giving a public demonstration of laughing gas, and in the audience was a dentist, Horace W ells. A volunteer from the audience injured his leg se verely on returning to his seat after inhaling the gas, but appeared to be unaware of pain. Wells noticed, this and next day submitted to the ex traction o f one of his own teeth while he was rendered insensible by inhaling nitrous oxide. The story is well known, and although con troversy exists concerning the priority o f nitrous oxide vis-a-vis ether in the discovery o f anes thesia, nothing can deprive Horace Wells of his place in history as a man whose powers o f ob servation, supplemented by the initiative to base an experiment on what he had seen, brought great benefit not only to his patients but to all mankind. Prospects for the prevention o f dental caries
h a v e ad v a n c e d su b sta n tia lly o v e r th e p a s t tw o d e c a d e s. G iv e n th e sam e ra te o f p ro g re ss, less tim e th a n th a t m a y b e n e c e ssa ry to releg ate this d ise a se to a p o sitio n o f m u ch sm aller signifi c an c e th a n it c o m m a n d s at p re se n t. F o r se v eral y e a rs p a s t, c a rie s re se a rc h h a s b e e n d o m in ated b y in v estig atio n o f th e b a c te ria l co m p o n e n t o f th is d ise a se . T h e in v o lv e m e n t o f b a c te ria in th e p a th o g e n e sis o f to o th d e c a y w as p o stu la te d by se v e ra l a u th o rs b e fo re th e tu rn o f th e c e n tu ry . F o r a long tim e a fte r th a t th e w ay w as lo st, b u t w ith h in d sig h t it is n o w p o ssib le to d isc e rn th at th e tru ly sem in al a d v a n c e o n w h ich so m uch p ro g re ss h a s b een b a se d cam e from th e re se a rc h o f J . K ilian C la rk e in 1924. A t th e b e h e s t o f the D e n ta l D ise a se s C o m m itte e o f th e M ed ical R e se a rc h C o u n c il, C la rk e h a d c a rrie d o u t an in v es tig atio n to d e te rm in e “ if th e re w as reg u larly p re se n t in early c a rio u s le sio n s a specific o rg a n is m .” H e c o n c lu d e d th a t “ c a rie s is d u e to in fectio n o f th e te e th b y a h ith e rto u n d e sc rib ed stre p to c o c c u s ” an d h e g av e it th e nam e o f S t r e p t o c o c c u s m u t a n s . T h e fa c t th a t C la rk e ’s w o rk
lay u n u se d fo r 30 y e a rs th e re a fte r is a n o th e r m a tte r. F o r th e p re se n t, th e im p o rta n t le sso n to learn is th a t by invoking C la rk e ’s skills to u n rav el this p ro b le m , th e co m m ittee re c ru ite d the help o f a sc ie n tist from a s iste r discipline. K ilian C la rk e w as su p p o rte d n o t by g o v e rn m en t fu n d s, b u t by m oney p aid by d e n tists a n d v o te d fo r th e p u rp o se o f re se a rc h by th e ir ele cte d re p re se n ta tiv e s. P e rh a p s it w ould be as w ell to re m e m b er th a t th e re is no help like selfhelp. F in ally , a p le a fo r ad d itio n al su p p o rt fo r r e se arc h c an be ju stifie d only if th e quality o f d e n tal re se a rc h is m ain tain ed a t levels a ch ie v e d in o th e r sp h e re s o f biological in v estig atio n an d , esp ecially in existing eco n o m ic c irc u m sta n c es, if its d irec tio n is identifiably in c o n so n a n c e w ith th e n ee d s o f society. Dr. C o h e n ’s rem arks are excerpted fr o m “P riorities fo r progress in d ental research,” a lecture delivered at the E a stm a n D e n ta l H ospital, L ondon, in N o v e m b e r 1976, and published in the A nnals o f the R oyal College o f Surgeons o f England (59:368-373, 1977).
JADA, Vol. 96, May 1978 ■ 721
Much has been said about the gulf that divides clinical practice from laboratory investigation, and both would benefit if it could be effectively bridged. An awareness of research activity could infuse additional interest into the day-today routine of practice and, from the opposite viewpoint, if clinical problems and difficulties were constantly brought to the awareness of laboratory workers their research would inevit ably benefit. There can be no doubt that the substantial advances made in the science o f den tal materials over the past decade are in no small part due to the collective insistence of dental practitioners seeking improvement in the materials available for restoring or replacing damaged dentitions. Problems o f a purely biological nature are of much less interest to most clinicians and it is in this area that laboratory scientists are most fre quently criticized for esotericism or irrelevancy. Nevertheless, the possibilities of advancing knowledge would be sorely limited if the justifi able demand for envisaging an application were to be extended still further to an insistence that research can take its inception only from at tempts at prevention or therapy. It would be akin to training long-distance runners by permit ting them to practice only the sprint over the last 50 yards to the tape. Clinicians who have no patience with reports of research on rats, or the interpretation o f electron micrographs, or at tempts to understand the minutiae of molecular biology are decrying the research worker for the toil he expends on long-distance training— because they can envisage no more than the final burst in the finishing straight. Collaboration between dentists and scientists from other disciplines is most likely to be fruit ful when they share a common language. To this 720 ■ JADA, Vol. 96, May 1978
end it is all-important that dental graduates should be encouraged to enter into the study of different basic sciences. Dentistry needs den tally qualified anatomists and physiologists, biochemists and pathologists, microbiologists and immunologists; dentists, that is, who have been prepared to study the subject in depth and not merely at an abbreviated level sometimes implied in the prefix “ oral.” The ideal situation is that in which teams of research workers include dental as well as non dental scientists. Dental graduates do not pos sess exclusive knowledge in regard to the teeth and their surrounding structures, but it is un realistic to believe that people who have not en dured day-to-day acquaintance with dental dis ease can share the depth of understanding pos sessed by those who have. The story o f the discovery o f anesthesia bears repetition to illustrate this point. It happened that in 1844 a chemist named Colton was giving a public demonstration of laughing gas, and in the audience was a dentist, Horace W ells. A volunteer from the audience injured his leg se verely on returning to his seat after inhaling the gas, but appeared to be unaware of pain. Wells noticed, this and next day submitted to the ex traction o f one of his own teeth while he was rendered insensible by inhaling nitrous oxide. The story is well known, and although con troversy exists concerning the priority o f nitrous oxide vis-a-vis ether in the discovery o f anes thesia, nothing can deprive Horace Wells of his place in history as a man whose powers o f ob servation, supplemented by the initiative to base an experiment on what he had seen, brought great benefit not only to his patients but to all mankind. Prospects for the prevention o f dental caries
h a v e ad v a n c e d su b sta n tia lly o v e r th e p a s t tw o d e c a d e s. G iv e n th e sam e ra te o f p ro g re ss, less tim e th a n th a t m a y b e n e c e ssa ry to releg ate this d ise a se to a p o sitio n o f m u ch sm aller signifi c an c e th a n it c o m m a n d s at p re se n t. F o r se v eral y e a rs p a s t, c a rie s re se a rc h h a s b e e n d o m in ated b y in v estig atio n o f th e b a c te ria l co m p o n e n t o f th is d ise a se . T h e in v o lv e m e n t o f b a c te ria in th e p a th o g e n e sis o f to o th d e c a y w as p o stu la te d by se v e ra l a u th o rs b e fo re th e tu rn o f th e c e n tu ry . F o r a long tim e a fte r th a t th e w ay w as lo st, b u t w ith h in d sig h t it is n o w p o ssib le to d isc e rn th at th e tru ly sem in al a d v a n c e o n w h ich so m uch p ro g re ss h a s b een b a se d cam e from th e re se a rc h o f J . K ilian C la rk e in 1924. A t th e b e h e s t o f the D e n ta l D ise a se s C o m m itte e o f th e M ed ical R e se a rc h C o u n c il, C la rk e h a d c a rrie d o u t an in v es tig atio n to d e te rm in e “ if th e re w as reg u larly p re se n t in early c a rio u s le sio n s a specific o rg a n is m .” H e c o n c lu d e d th a t “ c a rie s is d u e to in fectio n o f th e te e th b y a h ith e rto u n d e sc rib ed stre p to c o c c u s ” an d h e g av e it th e nam e o f S t r e p t o c o c c u s m u t a n s . T h e fa c t th a t C la rk e ’s w o rk
lay u n u se d fo r 30 y e a rs th e re a fte r is a n o th e r m a tte r. F o r th e p re se n t, th e im p o rta n t le sso n to learn is th a t by invoking C la rk e ’s skills to u n rav el this p ro b le m , th e co m m ittee re c ru ite d the help o f a sc ie n tist from a s iste r discipline. K ilian C la rk e w as su p p o rte d n o t by g o v e rn m en t fu n d s, b u t by m oney p aid by d e n tists a n d v o te d fo r th e p u rp o se o f re se a rc h by th e ir ele cte d re p re se n ta tiv e s. P e rh a p s it w ould be as w ell to re m e m b er th a t th e re is no help like selfhelp. F in ally , a p le a fo r ad d itio n al su p p o rt fo r r e se arc h c an be ju stifie d only if th e quality o f d e n tal re se a rc h is m ain tain ed a t levels a ch ie v e d in o th e r sp h e re s o f biological in v estig atio n an d , esp ecially in existing eco n o m ic c irc u m sta n c es, if its d irec tio n is identifiably in c o n so n a n c e w ith th e n ee d s o f society. Dr. C o h e n ’s rem arks are excerpted fr o m “P riorities fo r progress in d ental research,” a lecture delivered at the E a stm a n D e n ta l H ospital, L ondon, in N o v e m b e r 1976, and published in the A nnals o f the R oyal College o f Surgeons o f England (59:368-373, 1977).
JADA, Vol. 96, May 1978 ■ 721