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Posted by: The Probe 13th October 2021
For much of their interwoven history, those working in medicine and dentistry have tried to develop a singular model of the body and universal solutions for maladies. Every single human being is almost bewilderingly unique, yet for the longest time there has been an almost one-size-fits-all philosophy to patient treatment. Obviously, this is something of an exaggeration – we do, of course, look to the particulars of any given case to devise a treatment plan. However, there is much more we can do to personalise treatment and we should strive to do so.
This year, two decades after the Human Genome Project was first declared complete, headlines announced that the human genome had finally been sequenced from telomere to telomere. Previously difficult and complicated regions of the genome were finally filled in. This is a truly impressive accomplishment, however, at present the Y chromosome has still yet to be completely sequenced, and even this reference genome is a composite built from a small number of genetic samples from European heritage. A human genome has been sequenced, but the degree to which it represents all humans will only be known in time, so it is representative and not truly comprehensive.
The field of pharmacogenomics is an aspect of personalised medicine that is seen as increasingly important to improving treatment outcomes. Pharmacogenomics aims to further advance our genetic understanding, promising that healthcare professionals will be able to look for tell-tale genomic markers that should better predict pharmacological outcomes. At the moment, many patients still receive medication that is ineffective, produces adverse reactions, side-effects, or otherwise works differently to how the prescriber would hope. As more and more patients are sequenced, this will enable a more precise approach to prescribing patients, cutting down on waste and discomfort while increasing treatment effectiveness and pre-emptively avoiding adverse drug reactions. The NHS has ambitious plans to incorporate genomic services into routine care, with an aim to sequence half a million genomes by 2023/24.
Even as we race to improve our genetic understanding of patients, and the specific ramifications that our genes have on their needs and treatment plans, we are also beginning to see just how much more complicated the picture is. Our genetic instruction set is but one part of the puzzle, for our bodies are not singular works of architecture following a blueprint, but vast colonies that are shaped over time. Our unique microbiome contains at least as many bacteria as we have human cells, with some estimates putting the number at ten bacteria to one human cell or more. The influence of the oral microbiome on diseases such as gingivitis and caries is well-established, but there are also indications that the oral microbiome may play a part in more conditions well outside the oral cavity, including respiratory infections and Alzheimer’s disease. In time, tailored approaches may be able to more fully take into account the particular make up of a patient’s microbiome, identifying risk-associated microbial strains and giving improved advice and treatment as a result.
More personalised approaches to treatment are also being developed for dental implants, notably the Zygoma Anatomy-Guided Approach otherwise known as ZAGA. This zygomatic treatment concept shifts the focus of treatment planning away from the classic technique, instead allowing the patient’s unique anatomy to guide treatment. This is facilitated by using a proposed classification system of five basic skeletal morphologies that have been documented in the zygomatic buttress-alveolar crest complex. This refinement aims to prevent soft tissue dehiscence and protect sinus integrity where possible to prevent late sinus-oral communication.
If you are interested in learning more about zygomatic implants and the ZAGA treatment concept, there is an exciting education opportunity coming up in Manchester. Lasting three days from the 3rd to 5th of November 2021, participants in this exclusive course will gain detailed insight into the ZAGA philosophy and an evidence-based understanding of the technique. You will develop working knowledge of different techniques and their pros and cons, including intra- and extra-sinus approaches. The course is headed by three luminaries in the field: Dr Carlos Aparicio – creator of the ZAGA method, Dr Rubén Davó – one of the foremost zygomatic implant experts in the world, and Professor Cemal Ucer – Specialist Oral Surgeon who leads the Centre for Oral-Maxillofacial and Dental Implant Reconstruction, an international ZAGA Centre based in Manchester.
As the old saying goes, if all you have is a hammer, every problem looks like a nail. Personalised treatment approaches help us better understand the specific needs of patients, helping us to select the best solution for a particular problem. The advantages of this more targeted philosophy are numerous, not least we can be considerably more effective and efficient. But perhaps the greatest benefit, in a time when patients increasingly feel unheard and trust is in short supply, is that we put the individual patient at the heart of their treatment. Instead of fitting a patient to a model, we model a treatment to fit the patient.
Prof. Cemal Ucer
BDS, MSc, PhD, FDTFEd., ITI Fellow, Specialist Oral Surgeon
Cemal Ucer first established an implant referral centre in 1995. He was awarded an MSc in Implantology at Manchester Dental Hospital following his research into guided bone regeneration and osteopromotion. He later gained a PhD for his clinical and laboratory studies into the factors affecting the success of implant treatment in iliac grafts and the investigation of the effect of skeletal bone density on implant survival. He has personally trained and mentored more than 1,000 dentists in implant dentistry as one of the main providers of implant education in the UK.
Cemal’s current clinical research interests include immediate implant placement, reconstructive bone surgery, nerve damage and the effect of bone density on the success of implant treatment. Academically, he has gained European recognition for his work on the development of a new framework for teaching and assessment of clinical competence in implantology. He is a co-author of the consensus paper produced by the Association for Dental Education in Europe (ADEE) following the first pan-European collaboration between EU universities to establish common training and assessment standards in dental implantology. He is an invited member of the working group convened by the FGDP (UK) and the General Dental Council (GDC) to update the Training Standards in Implant Dentistry (TSID) guidelines in 2012 and 2016.
Cemal is a Fellow of the Dental Trainers Faculty of the Royal College of Surgeons of Edinburgh (RCSEd) and a Fellow of the International Team for Implantology (ITI) and a member of Megagen’s MINTEC UK & I Board for education and clinical research. He is a member of the editorial board of JOMR (Journal of Oral & Maxillofacial Research) and the chair of the editorial advisory board of Implant Dentistry Today. Cemal is Professor and Clinical Lead of the MSc programme in Dental Implantology and a member of the Faculty of Examiners of the Royal College of Surgeons of Edinburgh’s Diploma in Implant Dentistry. He is a past president of The Association of Dental Implantology (ADI) (2011-2013).
Cemal has been appointed by FGDP (UK) to lead the working group to develop the “national standards in implant dentistry” which is due to be published later in 2018 following the completion of an external consultation process.
 Nurk S., Koren S., Rhie A., Rautiainen M., Bzikadze A., Mikheenko A., Vollger M., Altemose N., et al. The complete sequence of a human genome. [preprint]. bioRxiv. 2021. https://www.biorxiv.org/content/10.1101/2021.05.26.445798v1.full August 18, 2021.
 NHS England. NHS genomic medicine service. NHS. 2021. https://www.england.nhs.uk/genomics/nhs-genomic-med-service/ August 20, 2021/
 Sender R., Fuchs S., Milo R. Revised estimates for the number of human and bacteria cells in the body. PLOS Biology. 2016; 14(8): e1002533. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4991899/ August 19, 2021.
 Rohr J., Rozenblats A., Selga G., Cema I. The influence of the oral microbiome on general health. Stoma Education Journal. 2021; 8(1): 66-76. https://www.stomaeduj.com/wp-content/uploads/art-7-1-21.pdf August 20, 2021.
 Aparicio C. A proposed classification for zygomatic implant patient based on the zygoma anatomy guided approach (ZAGA): a cross-sectional survey. Eur J Oral Implantol. 2011; 4(3): 269-275. https://pubmed.ncbi.nlm.nih.gov/22043470/ August 20, 2021.
 Aparicio C., Polido W., Zarrinkelk H. The zygoma anatomy-guided approach for placement of zygomatic implants. Atlas of the Oral & Maxillofacial Surgery Clinics. 2021; 29(2): 203-231. https://doi.org/10.1016/j.cxom.2021.05.004 August 20, 2021.