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.