In essence, Developmental Dental Defects (DDDs = D3s) are dental
birth defects. They comprise a wide variety of disorders that
manifest as malformed (e.g. discoloured, soft, pitted) or missing
teeth. Whilst common and often problematic to the extent that many
consider them a public-health burden, these disorders traditionally
have received little attention at multiple levels (research,
practitioner, population health, public awareness). However, the
past decade has brought increased concern, particularly amongst
clinical specialists dealing with children, prompting formation of
The D3 Group.

Vision
The D3 Group was founded as a regional network that would draw
together existing interests from across the sector, leading to a
collective assault on the under-recognition problem that chokes the
field worldwide. It was envisioned that such amalgamation of
available strengths and concerns would also provide an
unprecedented kernel for translational research, whose nourishment
could benefit public health and economies globally. Of foremost
concern, there was remarkable ignorance over the gravity of these
dental defects (D3s), even within the oral healthcare professions.
Such a general lack of awareness, together with paucity of data
about morbidity and economic impacts, had left the field seriously
neglected from a research perspective. A cross-sector approach
seemed essential to address these problems and trumpet the field as
a research priority (i.e. aiming to convert from "researcher push",
to " health-provider pull"). Secondly, the field in general faced
several problems relating to smallness, fragmentation and lack of
focus (e.g. narrow thinking, gaps and duplications, subthreshold
mass, misplaced competition). Although a pleasing number of
workforce strengths existed in our region, these were of boutique
scale, largely independent, and scattered geographically. It was
clear that diverse benefits would arise through consolidation and
unity at network level, particularly if there was collective effort
to identify key problems and maximise outcomes through talent
pooling. With regard to research translation, there was need to not
only link existing islands of expertise but also to fill several
gaps as needed for an effective translational continuum. Crucially,
such workforce advances would provide a globally attractive target
for research funding, thus complementing the network's effort to
get D3s recognised as a research priority. A third problem area was
inadequate education, which unsurprisingly caused many of the
difficulties mentioned above. From a translational viewpoint,
particular concerns were primitive aetiological understanding
(which sullied attitudes towards prevention) and inconsistencies
surrounding terminology, diagnosis and treatment. Clearly, these
pivotal issues would be better tackled by a collective, aiming to
provide a common language and understanding for broader
dissemination. Finally, a key translational issue was the missed
opportunity to engage clinicians and clinical students in basic
research, and conversely with exposing basic scientists to clinical
reality (i.e. cross training and clinical awareness, respectively).
Similar problems existed in interfacing with public health as the
next tier up. Development of a network approach, together with
appropriate support structures, seemed attractive in these
regards.
Implementation
Building on early input from concerned clinicians who identified
Molar Hypomineralisation ("Molar Hypomin") as the principal D3
problem in our region, broader consultation was undertaken with
opinion leaders from clinical, research and public health arenas.
Research leaders were then assembled to identify strengths and
gaps, and to subdivide future efforts. A translational focus group
(comprising representatives from academia, hospital and specialist
practice) was established to plan research strategy and foundation
initiatives. Terminology and branding were developed, aiming to
make the field more accessible internally and externally. A
clinical co-director was co-opted and The D3 Group (D3G) was
launched in 2007 via a scientific/network meeting and website. D3G
public meetings were held periodically thereafter, making efforts
to engage across Australia and NZ (e.g. guest speakers, funded by
MRUFD). The oral healthcare industry was also engaged through
hosting of D3G meetings and research support. New research projects
were started, strategically covering basic, population and
translational aspects. Existing educational efforts were enhanced
to emphasise translational aspects and to reach more broadly across
society. Finally, new training opportunities were instituted,
catering to late-career clinicians and clinical students in
particular.
Translational outcomes
Good progress has been made bridging the chasm that classically
separates busy clinicians and scientists, to the extent that
several fruits of D3G's labour are starting to receive broad
recognition and uptake.
Unified identity
D3G has united the field regionally by engaging comprehensively
across the research, clinical and population health arenas, so
providing a "one-stop-shop" for those interested in D3.
Furthermore, the whole sector has been embraced through outreach to
industry and affected families, making D3G a world-first network of
this type. Replacing a forgettable tongue-twister, the new "D3"
appellation has given the sector a catchy label - this rebadging
has met with rapid adoption, being accessible to professionals and
the public alike. Through its composition and mission, D3G has also
made a defining statement about translational research (which had
been an unfamiliar concept for much of the membership). Already,
the sector's newfound visibility as a substantive cohort extending
across Australia and NZ (membership >100, growing rapidly) is
improving awareness of the D3 problem and regional strengths
available to attack it.
Clarification of the main problem and its research
worthiness
Responding to tractional needs for sharper focus, D3G has
prioritised Molar Hypomin as its primary concern - this choice
recognised high impact at population level, potential
preventability, and research tractability. For some this
necessitated shifting away from the classical focus on two other
D3s that, under the same criteria, rank as less problematic in our
region (i.e. amelogenesis imperfecta, dental fluorosis).
Conversely, by expanding the focus on Molar Hypomin to include
downstream impacts (e.g. caries susceptibility, need for specialist
treatments such as orthodontics), research marketability has been
improved markedly. Research worthiness has been further emphasised
by refining terminology to highlight the most problematic aspects
(cf. caries risk) and the potential for prevention. Addressing the
uncertainties about health burden, D3G's translational focus group
has undertaken a cost modelling study to assess incidence and
economic costs. Strikingly, the results put Molar Hypomin on par
with major cancers in terms of treatment costs at population level,
again highlighting the desirability for research into prevention
and cost-effective treatments (publication in preparation).
Strengthened research effort
Since formation of D3G, communications have improved between
researchers from across the region, particularly through regular
opportunity to share thoughts and findings informally at D3G's
scientific/network meetings. By bringing together researchers,
clinicians and public health workers, these meetings have also
provided an unprecedented environment for research translation. In
the Melbourne hub, planning by the research leaders group has led
to establishment of several new research initiatives and teams,
drawing in part on new "translational research talent" contributed
by late-career clinicians. For example, targetting mechanistic
understanding, an NHMRC-funded project explores animal models of
D3. At the other end of the spectrum, another project investigates
downstream risks and economic impacts of Molar Hypomin at
population level, and a clinical subproject investigates its
impacts on orthodontics - both these projects draw heavily on
clinicians' inputs, complementing those from career researchers.
And of further translational importance, a new clinical research
avenue exploiting proteomics and metabolomics has been started
(funded by MRUFD). The first publication, involving researchers
from 3 areas (dental academics, hospital dentist, basic
scientists), provided intriguing insights to the molecular
characteristics and pathogenesis of Molar Hypomin - thus opening
the door not only to important new questions of preventive
significance, but also to ideas for new products as follows.
Translation from "Bench to Chairside"
Cognisant of issues raised by clinicians repeatedly, the above
proteomics study led basic scientists to think of practical aspects
that might be exploited clinically (i.e. diagnostic and treatment
aids). With their follow-up work proving supportive (patent
pending), initial steps towards product development are now being
taken. Attractively, this advance will represent a full
translational cycle from clinical problem to clinical benefit via
basic science, should it come to fruition.
Better visibility and recognition
Visibility and recognition of the D3 field have improved
markedly since formation of D3G. For example, the founding D3G
website has elicited multiple contacts from outside the network
(e.g. interested practitioners, affected families), and articles on
D3G have appeared in practitioner magazines. Moreover, D3G leaders
have been invited to give numerous talks about Molar Hypomin
(science, clinical and public audiences) leading to broad exposure
of D3G and its translational activities.
Education and training
D3G is attacking the education and training problem on multiple
fronts, to good effect. For example, through repeat invitations,
D3G members have regularly combined to give "translational"
lectures via a tag-team approach, and a multi-level online learning
resource (catering for affected families, public health sector,
practitioners and researchers) is at an advanced stage of
development. Through their informality, the D3G scientific/network
meetings are proving a popular vehicle for cross-disciplinary
exchange, including presentations from less-experienced
contributors (students, clinicians). And through collaborative
training efforts directed largely at late-career clinicians and
clinical postgraduate students, the translational research
workforce is being strengthened vastly.
Funding and advocacy
Whilst most effort has been directed at establishment of the
network and pilot projects (both sponsored largely by MRUFD),
attention is increasingly turning to funding of D3G's enhanced
capability to undertake translational research. Rewardingly, D3G
teams have secured competitive grants from public and industry
sources (NHMRC, Dentsply), and two high-profile dental companies
(Dentsply, Colgate) have provided financial support for D3G
meetings. These and other visible indicators of traction have put
D3G in a strong position for advocacy, which has commenced both
locally (public health providers) and nationally (policy regarding
caries monitoring and treatment).
These outcomes suggest that D3G has made a strong start at
turning a poorly recognised dental problem into a public health
issue with community ownership. Given that such endeavours are
needed worldwide, D3G occupies a pioneering position that with
appropriate development could impact oral healthcare
globally.