Death. Taxes. Change. These "certainties" of life become very uncertain indeed when we try to see more than a few years out. Yet prudence demands that we look as far ahead as we can, and try to anticipate (and ideally to influence) the factors that will affect our personal and professional lives.

As a teacher, I think a lot about how we should prepare students for their careers in dentistry. We want our graduates to be up to date, of course, but that’s not enough. To stay current in a profession undergoing constant evolution (and occasional revolution), they’ll need flexibility, curiosity and discernment. To become leaders, they’ll also need a crystal ball.

Remember when ...

A lot can change in 20 years. As recently as 1960, dentistry was still largely a matter of caries. Most practices were dominated by "drill and fill," though extractions and their attendant restorations were all too common. This was not bad dentistry—it was just the way things were.

By 1980, fluoride had radically reduced the incidence of caries. Now that teeth could be reasonably expected to outlive the patient, attention turned to periodontal disease as the No. 1 threat. Prevention, not restoration, came to prominence. Advances in esthetics kept pace with a willingness to invest in lifelong dentition.

The next two decades saw a dramatic confluence of science, health and affluence, leading to really remarkable improvement in the oral health of most (though sadly not all) Americans. Extractions due to caries are rare today. Orthodontics is widely available to children and adults. Most people at least acknowledge the importance of periodontal health, even if their follow-through leaves much to be desired. To be sure, natural teeth are still lost; but for those patients, we now have reliable endosseous implants that deliver many years of nearly full function.

And these are just a few examples. Just in my own lifetime, dentistry has seen the advent of superior analgesia, the high-speed handpiece, genuine infection control, low-dose radiography, long-lasting composites—a long list of tools and techniques that we wouldn’t think of doing without. Each has been an unalloyed benefit to the patient, who enjoys far better oral health today than we did when we were children. The change has not always made life easier for us dentists, however, and we have had to make the investments in effort and dollars to keep pace. But keep pace we have.

What of the next 20 years? Without trying to be too specific, maybe there are some trends we can bank on.

SOME SAFE PREDICTIONS
The one thing we can predict with a high degree of confidence is that the population is growing older. And thanks to several decades of good dentistry, these older people will be in a better state of oral health than ever before. They will continue to demand a high standard of care and will expect to keep their natural teeth for their whole lives. They’ll also expect esthetic perfection every time.

A somewhat paradoxical result of good oral health will be that more and more of our patients have complicated medical conditions. Many will be taking medications that have a negative impact on their teeth and gums; a growing percentage will have contracted oral cancers, with all that implies for the oral surgeon restorative dentist. We’ll need a broad range of both dental and medical knowledge to manage these cases safely and effectively. There are those who believe there should be some sort of new specialty for dentists who deal with medically complex cases, but I disagree. We’re one profession, and we do ourselves no service by treating clinical sophistication as optional.

What’s less predictable is how this aging population will pay for its dental care. Demographics and macroeconomics are already increasing the burden on working-age Americans to pay for their elders’ health care, and it is not at all clear how this will play out for the baby boomers. One way or another, they will probably not enjoy quite the same long, comfortable retirement as did their parents. This new reality will occasionally collide with high expectations, and this too may affect the way we practice.

We can be confident that the technology of dentistry will continue to evolve. But I also predict ... BREAKTHROUGHS! Something big is going to happen in the next 20 years, something that will radically change the nature of dentistry. I just wish I knew what it was.

Perhaps somebody will find a drug that reverses periodontal disease. Or the dream of fully automated, instant, chairside fabrication of prosthetics will become a reality. Or a compact MRI scanner will supplant X-rays. There’s a wealth of genetic information just waiting to be exploited to treat or diagnose. What about the current flurry of interest in links between oral and systemic disease? Will it lead to a whole new treatment paradigm, or will it go nowhere? If history is any guide, the "next big thing" will not come from where we expect it, but will crop up somewhere else altogether.

Then there’s politics. The U.S. health care system is an inefficient jumble, and the demagogues make it seem worse than it is. There’s a pent-up public frustration that can’t be resisted forever, and before the next 20 years are up, state and federal governments are certain to do something. Much of the legislation may be hastily conceived, and dentistry probably will be affected in the long run. But these decisions will not be made in a vacuum, and we need to become part of the process. Unless we educate policy-makers about the factors that go into long-term oral health, I fear they may go down the well-trodden path that has led so many countries to uniformly mediocre care for all (except, of course, for those who can afford to bypass the system).

One last prediction: dentistry will be doing just fine in 2020. The profession will be more agile and sophisticated every year. The technology in our operatories and the systems in the front office will be dramatically different from today’s. One thing, though, will be familiar: our focus on every patient as a whole human being.

Yes, I think 2020 will be a very good year.