Our New York City dental practice has considered the systemic (whole body) relationship of dental disease for over two decades.  We have been obtaining periodontal cultures of patients with advanced gum disease, based upon the early work of Dr. Max Listgarten, since 1988.  The recent discovery of diabetes in a patient based initially on periodontal (gum) diagnosis is a case in point.  The Center for Special Dentistry is proud to work with Dr. Keith Berkowitz at the Center for Balanced Health in mid-town NYC.  The fasting glucose tolerance test they performed to diagnose the patient’s diabetes will contribute to the overall health of this 42 year young woman.

42 year old female presented for an implant placement in the space of tooth #18. Previously it was noted that the patient was having periodontal problems, had undergone several rounds of scaling and root planning and had been placed on amoxicillin with metronidozole to resolve the condition. A periodontal culture was taken to determine the type of pathogens and if any resistant strains were present. The lab results showed gram negative rods resistant to both of the antibiotics. The patient was placed on 500 mg Cipro BID 7 days. A follow up visit revealed the gums were in a better condition. The patient was also referred to Dr. Keith Berkowitz (www.centerforbalancedhealth.com) to test for fasting blood sugar levels due to the suspicion of a systemic cause of the periodontal condition, prior to implant placement. The blood test revealed a fasting blood sugar level of 139 and the patient was diagnosed with diabetes.  Dr. Berkowitz recommended controlling the diabetes with diet modification for this health-oriented, compliant patient.

Today, the patient was anesthetized and given proper surgical dressing. A flap was made from teeth 20 to18. A 6 x 9 mm implant was placed, as well as a 5.7 x 3mm healing abutment was placed out of occlusion. Slight enamelplasty was done on tooth 18 to allow room for the healing abutment, due to the severe mesial angulation of tooth 18. A panoramic film was taken to verify proper placement of the implant as well as proper seating of the healing implant. The tooth was left without a temporary for the time being to allow integration of the implant and bone.

N.D., New York University College of Dentistry

33 year old female presented for second stage implant surgery on tooth #10. Tooth #10 was lost due to an extraction by a previous dentist. It was mistakenly taken for a primary tooth. The implant was placed 6 months prior with no complications, and temporized with a Maryland bridge that was bonded to teeth #9 and #11 lingually.

Today the Maryland bridge was removed. Local anesthesia was given, and an envelope incision made. A healing abutment was placed and the occlusion adjusted to leave the abutment out of occlusion. A periapical xray was taken to demonstrate the proper seating of the healing abutment, and then it was torqued into place. The abutment was temporized using a duralay temporary and adjusted for proper occlusion. No sutures were needed. After proper healing of the tissue, a final impression for an implant crown will be taken.

N.D., New York University College of Dentistry

Today’s experiences encompassed the evaluation and editing of a complex treatment plan. The patient is a 57 year old female patient who is extremely phobic in the dental setting. Her past medical history includes smoking 1 pack per day, sinus problems, migraines, and dental phobia. Her chief complaint was that she wanted her top teeth fixed for her son’s wedding this upcoming summer.

The patient’s dental phobia is a major contributor in the execution of her dental care. Her dental phobia is so severe that she sent her husband to the first few visits to take care of the treatment planning instead of personally being there, and, due to past dental related trauma, when she is in the dental office she cries. She would like the treatment done all in one day and under IV sedation so that she can get it done as quickly and as painlessly as possible.

The patient would only like to focus on the upper arch at this time. She has #4-11, 13, and 14. She is missing #1-3, 12, 15, and 16. The patient has periodontal disease which could be classified as moderate to severe chronic generalized periodontitis, evidenced by photographs and radiographs. (Figure 1)

Figure 1. The moderate to severe chronic generalized periodontal disease is evident in this radiograph. Notice the low bone height on both the maxilla and the mandible.

Therefore, initial scaling and root planing of the upper arch is indicated. Although the patient also has the disease on the lower, the patient would only like to focus on the upper arch and the dentist would like to avoid any sensitivity on the lower arch. Because the patient is afraid of any possible pain from her dental work, endodontic therapy was suggested in all of the upper teeth to avoid the pain. On most of the teeth the endodontic therapy is not indicated for carious or disease related reasons, but primarily to avoid any post-operative pain.

After the periodontal and endodontic therapy is done, the planned restorations will be prepared and inserted. There will be crowns on #4, 5, 13, and 14 and there will be resin veneers on #6-11. The crowns will only be temporary since the patient would only like to come in for 1 visit. The temporaries will be placed under a condition that the patient will come back for final crown insertion within 6 months of this treatment. The veneers will be resin because the patient does not want to come back for another visit, which would be necessary if porcelain veneers were fabricated. The patient was informed that resin veneers are not as strong or long lasting as porcelain veneers.

In addition to the aesthetic work which will be done on the maxilla, there is also a concern of a red lesion on the hard palate. Since the patient smokes 1 pack per day, this puts her at a higher risk for oral cancer. The oral surgeon will examine and possibly biopsy the lesion during the visit. (Figure 2)

Figure 2.  The red lesion on the palate is of concern, especially since the patient is a smoker. An oral surgeon will examine and possibly biopsy the lesion.

All of this therapy will be done in one visit in order to comprehensively deal with the patient’s phobia of dentistry and pain. In addition, since the husband is the primary person involved in the treatment planning process, both the husband and the patient will sign the treatment plan, confirming that they both understand and agree to the treatment outlined.

Lateral, front, and occlusal views of the maxilla before treatment.

N.S., New York University College of Dentistry

Patient presented with a chief complaint of severe pain on the upper right. There was a root canal and crown done on #2 in the past, so before examination it was thought that perhaps this tooth would be the culprit. However, the patient was quite specific in pointing out that the pain was coming from the cervical region of #3. A periapical radiograph was taken and it showed that there was neither pathology nor caries.

It was determined that the pain was probably due to abrasion from abrasive tooth brushing habits. The area was slightly abraded with a high speed, acid etched, bonded, and composite was placed.

The patient was told that initially there may be more sensitivity but that in a few days the pain should go away. Should the pain not go away it may warrant further exploration and possibly necessitate endodontic therapy.

N.S., New York University College of Dentistry

Today’s session proved to be quite educational. Dr. Dorfman met with a newly graduated endodontist seeking career guidance. Dr. Dorfman frequently meets with young dentists and specialists to help them prepare for the transition to private practice. The meeting consisted of the endodontist showing some pre-operative and post-operative radiographs of her work to show her competency. In addition, she answered some questions regarding endodontic and emergency care and afterwards took a tour of the the office. Being included in this meeting provided me two different viewpoints. While one view may be more applicable to my current position as a graduating student, hopefully the other view will be applicable in a few years as I begin to build my own comprehensive practice.

N.S., New York University College of Dentistry

Patients seeking dentistry in New York City during this frightening economic period are primarily seeking more significant cosmetic and reconstructive dentistry. Ironically, the smaller dental work disinterests them now. Perhaps patients now have more time, or perhaps they are preparing for interviews.

New York University College of Dentistry is exploring the incorporation of evidence-based dentistry into routine clinical practice.  It will be interesting to see how it proceeds.

Today a female patient came in for insertion and cementation of veneers from #4-14. Previously the patient had veneers from #6-11, which she was satisfied with, but she wanted a full new set of upper veneers completed to make her smile beautiful. At the last visit the current veneers on #6-11 were removed and #4-14 were prepped and temped. At this visit the temporaries were removed by cutting them down the mid-facial aspect with a bur. Incipient decay was removed on teeth # 4, 12, 13, and 14. The veneers were tried in and shown to the patient before cementation, and the patient was quite satisfied with the shape, size, and color. The veneers were the cemented in with Nexus Base Clear, a very esthetic cement. Occlusion and esthetics were checked. She will return later for mandibular veneers.

Figure 1. The patient with veneers from #6-11. She was very happy with them but has a wide smile and would like the full smile to be veneered.

Figure 2. The teeth prepped for veneers. Minimal preparation is needed.

Figure 3. Some of the incipient lesions that were prepped to remove decay.

Figure 4. Occlusal view of the cemented veneers from #4-14

 Figure 5. Frontal views of the final veneers from #4-14.

N.S., New York University College of Dentistry

Listen.  Communicate.  Diagnose intelligently and honestly.  Work with a team.  Write a careful treatment plan and present it logically.  Be gentle.  Be quick.  Be artistic.  Be fair.