The reason why I decided to apply to the Center for Special Dentistry or “The Private Practice Elective” as it is referred to at NYUCD was not because I needed more clinical time, I believe that NYU gives plenty of opportunity to improve one’s clinical skills. The main reason was to get a real life experience working in a low volume, high fee dental practice and to observe all aspects of patient and office management.

Unlike the majority of the dental students I have significant real life experience working in the dental office. Before I started NYU I was managing dental office for approximately four years and I am familiar with a lot of the aspects of the practice and patient management. However, the office that I worked for was in a completely opposite side of the spectrum of dental practices. It was a high volume low fee office located in Harlem, mainly catering to Medicaid and union plans. After working in that type of environment I was very comfortable dealing with most of the patients that would come to NYU. I felt that my clinical skills were fine, but I wanted to get exposed to all aspects of treatment of patients that can afford elective work. That is why when I read the description of the elective and visited the Center for Special Dentistry I thought that this was a perfect opportunity to acquire the knowledge and skills that in was missing.

The Center for Special Dentistry is a state of the art dental facility that focuses on providing exceptional personalized care to each and every one of the patients. When I first came to the center I immediately noticed the size and layout of the facility. The place is big with large reception area and open desk layout where receptionist sits in the same room with the patients and not behind the bulletproof glass window and the door with the buzzer that can be opened only from the inside. This kind of open room or open desk environment makes patients feel more relaxed and it is very important considering the fact that a lot of dental patients are phobic.

The second thing that I noticed that corridors were not 36 inches as a minimal width required by law, they looked almost double of that width allowing for easy passage of several people at the same time without them bumping into each other. Corridor walls have large black and white photographs of New York giving the place this upscale atmosphere.

The operatory rooms are also mach larger than 7×8 that I was used to. They are large airy and all have nice view of Madison Avenue.

As I mentioned before the facility is state of the art. It is completely paperless, you will not see a file cabinet with charts and you will never run into a problem where a chart is misplaced. Charts were replaced with Dentrix practice management software. It is the most advanced dental practice management system on the market at this time. It allows for patient’s chart to be seen from any operatory and if necessary remotely from outside of the office. The software has a built in chair-side charting capabilities and incorporates digital imaging. Every operatory has built in digital extraoral and intraoral cameras and images go directly into Dentrix and get incorporated into patient’s chart. In addition to the extraoral and intraoral cameras every operatory has digital x-ray unit and in the similar manner as the images X-Rays also get incorporated into the software. Digital practice management has several advantages over the regular paper based. Perhaps one of the main once is the fact that one can back up the data including the images and in case if something happens to the office, data can be restored with no loss of patient’s information. Second recall and patient tracking system can be automated. Also with addition of the optional module billing can be done paperless through Dentrix. One can also track account aging.

As I mentioned above one of the things that I wanted to get out of this elective is the ability to effectively deal with patients who have no problem paying for elective treatment like implants and veneers. In my opinion that was one of the main things that I got out of the program. Dr. Dorfman has a very unique approach to all of his patients. Because the practice is strictly fee for service and is not booked 1 month in advance Dr. Dorfman and his staff can spend a lot of time with each and every patients listening to their fears, concerns and expectations. In my eyes the only way for the doctor to provide good quality care is to approach each patient the way it is done at The Center for Special Dentistry. The main reason why many people avoid seeing a dentist is not finances. It is a fear of a dentist or dentistry. Usually it has to do with past dental experiences where the patient was treated in the insurance clinic where the doctor does not even have time to properly anesthetize the patient. Where it is not the doctor and patient who decide what kind of treatment the patient will get. The decision is made by the insurance company. A person, who never went to dental school, never saw the patient gets to decide what the right choice of treatment is. As incongruous as it sounds this is the kind of dental experience most of the patients who go into insurance practices get. The experience that most of the patients in the insurance practice get starts in the waiting area along side with ten to fifteen other patients. Once you got an appointment that some time you have to wait for months you get into the waiting area where receptionist is sitting behind a bullet proof glass. There you spend up to three hours. After that you being sent into the chair, doctor walks in gives you anesthetic and leaves. When after a few minutes he comes back he starts to drill without any explanation of what is going to be done or verification if the anesthetic is working. Usually the actual chair time is less than thirty minutes and patient gets very little if any feedback in terms of what is being done and what is next. The Doctor physically does not have time to spend with the patient because the fee that the insurance company is paying is too low. In addition a lot of the doctors that work in this kind of setups ether never had or lost the ability to provide quality care that all patients deserve.

Sometimes the fear of dentist and dentistry comes from parents. The parents’ fear of dentist transfers to the kids and now kids are afraid if the dentist.

Dr. Dorfman has different approach to patients. Each patient gets as much of undivided attention as needed. Every question is being answered and every concern is being addressed. The big portions of the patients that come to the practice are phobic patients with previously failed dentistry. This kind of patients takes up a lot of time. And that is one of the reasons why these patients can’t be successfully treated in the insurance practices. I have seen many patients come in with fear and leaving with a smile.

There are other things that I learned during the time I spend in practice. One of them was the amount of time that Dr. Dorfman spends on the informed consent. The informed consent is a very important part of treatment. Before beginning of any treatment Dr. Dorfman compiles personalized informed consent. This is much different from the standard consent that most of the offices use where there is one very general page written in the very legal language that most of the people do not understand and no one really bothers to read and just sign exactly the same consent regardless of the procedure being performed. The consent that Dr. Dorfman writes are formulated to reflect only the procedures and complications related to the treatment that will be performed. The language of the document is very plain that anyone can understand. It also encompasses the period after the treatment and patient’s responsibility to maintain the restorations because no matter how good the dentist is if the patient will fail to properly maintain the restorations they will fail regardless of the quality of work. Unlike other practices where patients just given the consent to sign. In the Center for Special Dentistry patients are being explained every paragraph before they sign.

One of the biggest parts of the treatment is treatment planning. It is very important when you do complex multidiscipline treatment plans that all of the specialists will have a common idea of what is the final result should be. Every case gets careful review and if the services of the specialists needed patient sees the specialist before treatment plan is complete. In the regular office where there is no specialist available onsite patients being sent to different locations and specialists usually don’t know why are they taking out a particular tooth or doing a bone graft they do not see the big picture. In contrast in the Center for Special Dentistry every specialist before they do anything has a conference with Dr. Dorfman and discusses that “big picture”. They also have access to patient’s electronic chart view the x-rays, images and previous clinical notes. This collaboration of restorative dentists and specialists brings better final results and greater patient’s satisfaction. Not only patient does not have to travel to another unfamiliar office they get the best possible treatment in the environment that they came to trust.

This collaboration of the specialists and restorative dentists in addition to the stress-free environment for the patient assures accurate treatment planning. It also provides better, controlled environment where patient feels that everyone in the office has their best interest in mind. This environment facilitates accurate and seamless execution of the treatment and makes patient active and interested participants in all steps of the process.

I saw people’s smiles transformed and people’s attitudes toward dentistry and life change. Patients would come in uncomfortable to smile, shaking from anxiety and would leave relaxed, self confident, with a big smile on their faces. I saw the satisfaction that the doctors and staff gets from being able and having time to help each and every patient that comes through the door. This environment is unachievable in the insurance practice, they simply don’t have the time.

In the past year I learned a lot. I experienced many interesting and rewarding parts of my profession that I have never seen before and saw many aspects of dentistry for the first time. I saw the venues of achieving my coals and proof that it is possible. None of this would be possible if I did not spent time at The Center for Special Dentistry

Thank you, Dr.Dorfman, for a wonderful, life-changing educational experience that goes beyond dentistry.

Igor Elperin

NYUCD Class of 2010

Recipient of the 2010 Academy of Osseointegration’s Outstanding Student in Implant Dentistry Award

Recipient of the 2010 NYUCD Award for Outstanding DDS Excellence

Member of

AACD, AGD, AO, ADA, ASDA, ADEA

Drug-induced Gingival Hyperplasia (DIGH)

My exercise today was to look over a patients record and figure out what the possible treatment options are for the next phase of dentistry.

Chief Complaint: Patient wants to explore treatment options regarding possibility of restoration of anterior dentition. He is open to dentures, implants and any other options. Patient is very phobic, repeated past history of failed dentistry. No dental visits in the past several years.

Relative medical history: Patient has HTN and is taking a calcium channel blocker
Drug-induced gingival hyperplasia (DIGH):
Inflammation of the gingival tissue from bacterial plaque and the subsequent development of gingival crevicular fluid may allow sequestration of the calcium channel blocker, thus predisposing the tissue to a localized toxic effect and the development of gingival hyperplasia. All of the available calcium channel blockers have been reported to cause gingival hyperplasia.

Treatment options include meticulous plaque control, and in severe cases, gingivectomy. Drug-induced gingival hyperplasia (DIGH) is an iatrogenic dental disorder that is characterized by gums that are enlarged and inflamed, and bleed readily upon probing. The gums appear lobulated from papillary enlargement, and the tooth crowns may be partially covered by hyperplastic tissue. Drug-induced gingival hyperplasia is usually only cosmetically disfiguring; however, the formation of tissue pockets can interfere with proper oral hygiene, contributing to periodontal disease and dental caries. Patients who develop DIGH are at risk of treatment failure because of noncompliance. Those who develop severe DIGH may eventually require invasive oral surgery, such as a gingivectomy. (D.B. Lawrence et alJ Fam Pract 1994; 39:483-488)

Initial therapy consisted of scaling and root planing, extraction of four lower incisors that had severe bone loss, and provisional restorations in the edentulous space. After scaling and root planing was completed, and four lower incisors were extracted, provisional restorations were fabricated using Luxatemp. Luxatemp is the temporary crown and bridge material - internationally successful for more than 10 years and Number 1 in the USA since 1997. Luxatemp was the first bis-acrylic composite that was offered in the advantageous 10:1 mixing ratio for automatic mixing. Other advantages are Luxatemp’s outstanding biocompatibility and the safety cartridge developed by DMG. (http://www.dmg-dental.com/produkt.php?lan=en&produkt=58. ) A provisional bridge was fabricated using teeth #22 and #27 as abutments.

Stage two of the treatment will involve permanent restorations in place of extracted teeth to restore esthetics, phonetics and function. The following is what was proposed by me as possible treatment options:

To properly evaluate possible treatment options, the first step would be to conduct radiographic examination using cone beam CT scan which gives dentists a 3D evaluation of the remaining bone. Given the severity of periodontal involvement, a regular 2D image may not be sufficient evaluation tool. If the remaining bone in the mandibular anterior region is sufficient to accept implants then several treatment options are available:

First treatment option:
Placement of four single-unit implants and restore them with four Zirconia abutments and Alumina-porcelain single-unit crowns. Use of the non-metal abutments and crowns will give more natural looking results than conventional porcelain fused to metal crowns and metal abutments.

Second treatment option:
Placement of four single unit implants and restoring them with conventional metal abutments and four porcelain, fused to gold, crowns.

Third treatment option:
Four single unit implants and restoring them with a four-unit bridge. This option will give additional stability to the final restoration but will compromise the ability to thoroughly clean the area. For the patient with already compromised gingival health, this may not be the best solution. Porcelain fused to metal or Zirconia can be used to as the bridge material.
One of the obstacles to overcome with the above mentioned treatment options is the difficulty of achieving a good emergence profile and good esthetics in the region of the central incisors.

Fourth treatment option:
Placement of two implants in place of the lateral incisors and fabricating two two-unit bridges with central pontics having ovate gingival contact area; this will give an illusion of pontic coming out of gingiva. This approach will give a more predictable central papilla and emergence profile in the central incisor area. This option will also be the least expensive treatment involving implants for the patient. As far as the choice of the materials for this treatment option, we can use ether conventional metal pontics and porcelain fused to metal bridge or Zirconia pontics and Zirconia fused to porcelain bridges. Even though Alumina gives better esthetic results, use of alumina for the frame of the bridge is not recommended.

Fifth treatment option:
Placement of two single unit implants and restoring them with a four-unit bridge. Advantage of this method is additional stability and disadvantage is limited cleansibility. If the width of the bone in the anterior region of the mandible is inadequate, a procedure called “ridge augmentation” can be performed to add bone to the region. This procedure will increase time of the treatment by approximately nine months, which is necessary for proper bone healing. In a case of inadequate bone height, other options that do not involve implants must be considered.

Options that do not involve implant dentistry:

Option one:
Eight unit porcelain fused to metal or porcelain fused to Zirconia bridge spanning from #21 to #28 using #’s 21, 22, 27, 28 as an abutments and # 23, 24, 25 ,26 as pontics.

Option two:
Six unit porcelain fused to metal or porcelain fused to Zirconia bridge. This treatment choice however has the poorest prognosis of any other treatment option mentioned above due to the fact that the canines have less than 70% of the bone remaining, compromising support of the bridge. According to Ante’s law, the sum of all root surfaces of the teeth to be replaced by pontics should be less or equal than the sum of the root surfaces of all abutment teeth. Since there is great bone loss in the canine area the sum of the root surfaces of the abutments will be less than the pontics. Additionally, cleansibility of the area will be impaired facilitating gum disease.

Finally, there is a last option that patient was originally inquiring about: a removable partial denture.

Final thoughts:
As with any fixed treatment in patients with severe periodontal disease, any treatment outcome will depend on the level of patients’ involvement in his oral health. Meticulous oral hygiene has to be implemented to reduce the effect of periodontal disease: brushing at least twice a day but preferably after each meal, flossing at least twice a day, use of a Peridex mouth wash once a day one week out of a month for life. Repeated visits with a periodontist for perio maintenance and/or any other active therapy. The patient needs consultation with his physician to explore an option of switching to a different class of medications that will not result in gingival hyperplasia. Only with this kind of involvement can we expect any relatively predictable outcome, without it any treatment will result in premature failure.

I.E., New York University College of Dentistry