A 48 year old male patient presented for restoration of tooth #29 DO with composite. Patient had an amalgam filling in the tooth and according to a PA, there was a recurrent decay present around and on the gingival floor under the temporary filling.

I went in with a 1556 bur and removed the amalgam filling to assess the amount of decay present under it. I also removed the temporary filling to assess the remaining amount of decay. Under the amalgam there were a few spots where decay process had begun. Also, on the distal wall, there was extensive decay. After having reevaluated the PA that we had available for #29 to see the depth of the distal axial wall decay, we also became suspicious of the mesial side of #29 where we saw a radiolucency that could have been potential decay. In order not to come back to #29 later in the treatment process, we decided to take another bitewing centered on the mesial of #29.

R.F., New York University College of Dentistry, Patient 2

Patient presented with the chief complaint that she wants to do something about her maxilla (upper jaw). She is missing most of her maxillary teeth and some teeth on the mandible. Although her mandible requires a lot of work, her financial situation does not permit her to take care of the full mouth and this is why she wants something done about her maxilla.  According to a PAN, on her maxilla she has present #2, #12 and #13 and root tips of #6, #7 and #11.

According to a PA, #2 is slightly mobile but has no infection around it. Keeping #2, besides its mobility, is a good idea because it is the only posterior tooth on the patient’s upper right quadrant and it provides stability to the occlusion on that side.  Because the patient has healthy #12 and #13 that provide support in the UL quadrant, root tip #11 will be extracted.

Root tips of # 6 and #7 are critical for the anterior occlusion support because there are no other maxillary teeth in the front. #6 and #7 can be used as potential abutments for crowns which would help the patient establish her anterior occlusion. In order to put crowns on #6 and #7 we would need to do crown lengthening, root canal therapy and cast post and core on both teeth.

However, in order to get a better crown-to-root ratio we would need to remove some gum from the front via alveoloplasty.

Generally, her occlusion is mostly ok except for the anterior part where the maxillary gums touch the mandibular front teeth and alveoloplasty would be probably indicated in order to put crowns on teeth #6 and #7. We were going to offer the patient implants on the top along with implant restorations, however her financial situation does not allow that and that is why the patient is probably going to go with zest attachments for the overdenture. Another option would be getting a partial denture for the patient’s upper arch; that is only if we try to keep the top 3 teeth.

In case we do the maxillary partial denture, patient has to be informed that just 3 teeth might not keep the denture stable and these 3 teeth might move or crack under loading.

This is why, in this case, considering the financial situation of the patient, it is better to go with the maxillary implant overdenture which has a better long-term prognosis than the maxillary partial denture because an implant overdenture will draw its retention from the zest attachments which are going to be anchored by the implants set in bone.

R.F., New York University College of Dentistry, Patient 1

Today in the dental office there was a case that was very complex not only because of the dental work that was involved but because there was also issues of finance and patient management involved. The patients was chief financial officer of his company and had a lot of dental work that needed to be done. This patient was overweight as an adolescent and suffered from anorexia and bulimia. These two disorders ruined his upper teeth and neglect over many years worsened the situation. When he presented to the office the patient had almost no coronal tooth structure left on any of the maxillary teeth.

It was charted that 6-11 and 14 and 15 were restorable with guarded prognosis and any other root tips in the mouth were to be extracted. 6-11 and 14 and 15 were all to be treated with RCT in one visit and to be restored a few days later also in one visit with temporaries.

One of the main concerns with this patient was the loss of vertical dimension. After many years of going with the wrong vertical we were concerned that opening the bite again would cause stress to the TMJ. After endo and OS consults however it was deemed that restoration of the occlusion could be done immediately. It was also noted that this patient was very phobic and was pre-medicated prior to any treatment for the phobia.

The treatment time was about 4 hours in which 8 root canals, post space preparations, and impressions were done. The lab tech was on hand to observe the case so that he could process temps for the patient within 4 days when the post/cores are inserted. This is a case that would normally have taken months and a lot of patient visits but is going to be taken care of in a short span of time with specialist attention.

H.A., New York University College of Dentistry, Patient 10

Today at Dr. Dorfman’s office I got to see a new procedure. Yesterday a patient came to the office and had RCT done on tooth #8. This patient had visited the office previously with a chief complaint about tooth #8 which had changed color within the past 3 months and she wanted to whiten it. Even though external bleaching was performed on that tooth it had not changed the color, so the decision was made to do an internal bleaching. So after the RCT was completed the tooth was then filled with bleaching material and packed with Cavit. Overnight the patient achieved the desired result. However the tooth became one shade lighter and the patient felt as though the tooth was too light compared to the adjacent teeth.  

When she presented we were able to concur on the discrepancy in color. The patient however was happy with the result of the bleaching and felt that she wanted all her anterior teeth to be that shade.

We started the procedure by removing the cavit and rinsing out the bright red bleaching material. It was important to watch the buccal wall of the tooth and to watch how apically the tooth was being prepared in order to avoid ruining the endo fill. After all the material is rinsed out we see that the access has been preserved and it is ready to be filled with composite until it is deemed necessary to fill it. It is important again to create a barrier between the gutta percha and the composite fill with a layer of cavit. After the final fill and polish the patient made an appointment to have full arch, maxillary and mandibular bleaching.

Later in the day a patient of 15 years came in and needed a new crown on #2. It was interesting to see a different way that an existing PFM, which had decay on the distal margin, was removed in order to prep the tooth for a new crown.

H.A., New York University College of Dentistry, Patient 9

Today a treatment plan was discussed with the patient. The patient presented with braces of 2.5 years that were placed in another practice. The ortho had failed and had caused much damage to the patient’s teeth. There are perio, operative, endo, and cosmetic issues. The patient has opted out of correcting the issue with further orthodontic treatment. The treatment plan that we present to her should allow for orthodontic treatment in the future should the patient want it. Limited budget is another obstacle in this case.

On her first visit the patient is having her brackets removed under nitrous. On her second visit she will have a hygiene visit. We will allow a few weeks for the gums to heal. In the meanwhile after 4 bitewings are retaken we will start restorative work on her. We will do any cosmetic work in the anterior region after we see improvement in the gingiva. After all work is done patient will have her wisdom teeth extracted, have a lingual fixed retainer placed on the mandibular teeth and a bite guard will be made in order to increase the half life of all procedures.   

H.A., New York University College of Dentistry, Patient 8

My next dental patient came in for an in-office tooth bleaching. She came in because she felt that her teeth were a bit too yellow and she wanted to have bleaching done. The in-office bleaching was done differently than dental school. The bleach we used in the office was much stronger due to a higher concentration and it didn’t involve mixing two different tubes. We did two applications for 12 minutes each and then the patient was given post-op instructions! She was happy with the result of the maxillary anteriors but wants the mandibular anteriors to be a little bit lighter. She will wait for 2-3 days and see if the color changes at all and if not satisfied with the final result she will come in again for a second bleaching visit.

H.A., New York University College of Dentistry, Patient 7

Today I was able to observe a tooth bonding procedure and do an in-office teeth bleaching. The first patient was a former model and she was quite fun to work with! She came in because she didn’t particularly like the appearance of her maxillary and mandibular anteriors and she also had a number of amalgam fillings with recurrent decay! When she smiled you could instantly notice the asymmetry in her smile was coming from her maxillary anteriors. The mandibular anteriors also were all inclined towards the mesial causing crowding. In the office, Dr.Dorfman did bondings on #10 and #4 because the patient noticed that she had some yellow staining on those teeth. Tooth number 10 had a bevel placed on it so that the B1 composite shade wouldn’t contrast with the actual shade of her teeth. The same shade was used on #4 and the patient was happy with the result of both bondings. The patient also had a number of class 3 restorations as well as a number of other concerns which will be addressed in her next visits. She also had enameloplasty performed on #8 and #11 because #8 was causing trauma to her lips every time she smiled and #11 was out of the occlusal plane and looked like a fang.

The patient has the option of getting invisalign to straighten out her mandibular anteriors and then having a retainer put in to maintain the shape. Even though she has the option of leaving her teeth as they are, most likely she will be paying a lot more attention to them since she noticed that many people who live around her, on Park Avenue, have so much money and don’t fix their teeth and she doesn’t understand why!

H.A., New York University College of Dentistry, Patient 6

Today I observed a consultation from start to finish. The consultation was with a woman who, as a child, had a maxillary lateral incisor extracted and ultimately the orthodontist moved all the posterior teeth forward in order to close the space. At the time she was told that putting in an implant would be too complicated and so the patient just underwent the treatment without the implant. 8 years later she presents to this office unhappy with her smile and the positioning of her teeth. She said that her teeth were pushed too far back and that when she smiled her teeth didn’t look nice to her. She found out about Dr. Dorfman’s practice online and she was presented with a diagnosis and a few different treatment options.

Since she had the teeth moved in and forward to fill the space of the laterals, the maxilla was constricted. In order to compensate for this, her mandibular teeth shifted inwards and therefore looked like they were pushed in. She has less than 1 mm of an over-jet. She was told that doing veneers would be a good option to cosmetically move her smile outwards but they would be unable to fix the over-jet. The patient was concerned because one of her friends had veneers done and she wasn’t happy with the result. The next option for this patient was to have braces and undergo orthodontic treatment for 2 years to re-open the space and then to have an implant placed to restore #7. The patient had ortho once and was not at all thrilled about this option. She then asked if she could have a surgery. This was also an option for her and a consult would of course be necessary with the oral surgeon. The patient also asked about invisalign. She was informed that in her case invisalign could be used to fix the maxillary teeth but fixing the mandibular teeth with invisalign is more difficult because of the nature of the bone and the inclination of the teeth. The patient seemed to want a quick fix in order to improve her smile. She will bring her x-rays for an additional consult.  

A very important thing I learned earlier in the day was a way to communicate with the patient about dental terminology in “English.” It is difficult to explain conditions and procedures to the patient using dental terms such as pulp, dentin, amalgam, tubules, etc. When explaining to the patient that an amalgam restoration could conduct heat and cold and cause sensitivity to a tooth in the absence of a liner, especially in deep fillings, it was surprising how easily I forgot that the patient had no idea what all of these terms meant. It is our job to educate them. The correct way to explain all of this is to say, “Metal fillings conduct heat and cold, so in order to protect the tooth you need to put something between the tooth and the filling that doesn’t conduct; and this is what a liner does.” It seemed so simple once it was explained but I didn’t realize how confusing it can be for the patient to try to understand all of this without a background in dentistry.

H.A., New York University College of Dentistry, Patient 5

Today, I observed the periodontist in the evening. The Arestin treatment that was done in that visit was a new learning experience for me because in perio classes in NYUCD we have been taught the various treatment regiments but I have never seen anything outside of scaling and root planning. It was interesting to watch antibiotics being administered directly into the area of the infection. In school many times I have been told by faculty to use hydrogen peroxide while doing an SRP to inhibit the growth of anaerobic bacteria in the area of PDL; that is because while doing an SRP gets rid of plaque and calculus, many of the bacterial populations remain unaffected. By administering antibiotics directly at the site of aggravation we are addressing the problem where it starts as oppose to just eliminating the result of the problem.

H.A., New York University College of Dentistry, Patient 4

My first patient today needed a bonding on tooth #2.

The patient presented with an occlusal sealant underlied by black staining and caries. The patient was anesthetized with carbocaine and the procedure was started. The cavity was excavated; and as I proceeded the cavity got deeper and deeper. The patient was informed that the decay is extensive and that there are also cavities on other teeth in the mouth as was seen in the x-ray. The patient however decided to wait for her insurance before she started her other restorations. 

The decay was excavated the bonding was completed. The bonding was redone due to a void on the distal of the restoration. Once the restoration was completed occlusion was checked and adjusted.

I have learned many things. There were a number of unexpected challenges; working in an unfamiliar operatory was a challenge for me despite having been on the clinic floor for over a year. Light curing, taking pictures, chair positioning, patient communication and hand pieces were all new to me and made the procedure much more challenging. I am used to finishing a bonding procedure in about 45 minutes, but it took me about 2.5 hours today and that was quite surprising. The tooth I was working on was the second molar and visibility, moisture control and drilling all became even harder and increased the amount of time it took me to complete the procedure.

H.A., New York University College of Dentistry, Patient 3