There is a HUGE opportunity for Apple in dentistry. Most major Dental Practice Management and Imaging Software Platforms are pc-based, closed source, bulky and require huge capital expense for in-office hardware, software and ongoing maintenance. Two Henry Schein (NYSE) subsidaries, Dentrix and EZDental, are examples.

We are developing 1dentist Software to offer lean, Open Source Cloud Computing and SaaS. Our early data shows significant interest from dentists within our 500 dentistry urls worldwide at 1dentist.com.

And even Kodak should refocus on open source digital medical and dental imaging, e.g. CT, MRI, x-ray and photography. Dexis (Danaher) currently has significant market share of dental imaging and is closed source.

Read The Wall Street Journal article.

Today a 31 year old female presented for an external bleaching. The case was interesting in that a maxillary central incisor presented with much darker staining due to a previous root canal therapy treatment completed at a different office. The goal of the external bleaching performed today was to not only to lighten all of the teeth, but to attempt to gain a few shades of whitening for this darkened tooth in particular. The teeth were properly isolated with liquid dam material. At the beginning of each cycle of bleaching, the darker central incisor was bleached for 4 minutes. Then bleach was added to the remaining teeth and the teeth were bleached for 12 minutes. Two cycles were completed. Upon completion the central incisor had lightened several shades. The patient had little post-op sensitivity. She was happy with the esthetic results.

N.D., New York University College of Dentistry

Patient presented for emergency visit at Dr. Dorfman’s office with a broken filling on tooth #20.  Patient did not complain of any pain or swelling.  Tooth #20 was badly decayed and the only option other than extraction was to perform Root Canal Therapy, crown lengthening, gold post and core, and a porcelain crown. The patient decided to save his tooth and we began work immediately.

Root canal therapy was performed by the endodontist. Right after RCT the patient saw the periodontist for a crown lengthening procedure. After the procedure, healing dressing was placed and patient was scheduled for a recall. After 1 week the dressing was removed and I began preparing the tooth for a post and core. I took a final impression with Impergum in a triple-tray for fabrication of a gold post and core to fit the tooth.Three weeks after healing, and after making sure that the crown margins would not be exposed, preparation margins were defined for a porcelain-fused-metal (PFM) crown with a chamfer finish and the final impression for a crown was taken. Together, we chose a color shade and  I wrote a lab prescription.

In the final appointment the crown was cemented with the glass ionomer cement. The patient was extremely happy with the outcome of this treatment. The patient was also made aware of other dental needs and decided to take care of his other teeth to avoid emergency visits in the future.

P.B., New York University College of Dentistry

Today I observed an orthodontic braces consult with a teenage tv celebrity. He had orthodontic treatment previously but #10 had relapsed to its original position because of failure to wear his retainer. The patient had also developed a crossbite in both canine areas.

Normally, for a patient who has not complied with previous treatment an orthodontist would opt for fixed braces, however this patient presented a unique case. Being a singer and celebrity, the patient needed something that would be esthetic for performances and television time. In dental school we are taught about creating an “ideal” treatment plan, and then alternatives if the patient cannot choose the ideal plan for whatever reason (cost, esthetic issues, etc). The ideal treatment plan is generally created on scientific foundations. However this case shows us that this plan cannot be created just on science alone.

If we don’t have compliance, science can be thrown out the window. Fixed appliances are definitely the best scientifically, and best for the orthodontist because they can be assured of usage. But it would not allow this patient to continue his life normally, since he is a celebrity. The dentist has to treat the person, not just the teeth! In this case, the challenge was not moving #10 back, but doing so without affecting the patient’s career activities.

Clearly with this patient it would not be possible to put anything fixed onto the buccal surfaces of his maxillary teeth. That really left two options, a spring aligner or Triple Star trays. Once the treatment objective was attained, a bonded lingual retainer would be placed from #7-10.

How to treat the mandibular teeth, in particular the anterior crowding, became a topic of debate. When on stage, the patient’s mandibular teeth would not really be seen, usually only the incisal thirds of the teeth, so a wire could be placed without being seen during singing or other activities. The patient was apprehensive, but made the decision with his father to go through with it, because he understood realistically he would need a fixed appliance for the mandible. He was informed that it was better to do it now, rather than when he would be older, and the teeth could have move even further from ideal positioning.

Also Dr. Dorfman explained to him that at any point in his treatment he could opt for one of the alternative treatments. Nothing was irreversible, appliances could be taken off, and this went a long way to reassuring him that his singing and acting activities would be able to go ahead as planned. Also Dr. Dorfman examined his bite once again and found that the lower anteriors would need to be sculpted in order to place the lingual retainer from #7-10.

So the final treatment planned that both father and son agreed to was:

Maxillary arch- a spring aligner or Triple Star trays to align #10 followed by fixed bonded lingual retainer (#7-10)

Mandibular arch- fixed appliance to align lower anteriors with sculpting followed by bonded retainer

It is important to note that the treatment plan was signed by the father today. The patient often comes here without his father, and usually with someone else, such as an assistant. So it was very important to get the father’s consent before starting any of the work. Finally at the end of the visit, alginate impressions were taken, and the patient was told he would need to return to have some sealants placed and begin the orthodontic treatment.

Interestingly at the end of the appointment, when the patient was about to leave, he mentioned that he had problems with his jaw locking on opening. There are many possible causes to his locking. Being young and still growing can contribute to jaw locking by abnormal growth patterns. Chewing gum can definitely cause TMJ issues, and of course being a singer extra care must be taken with his TMJ health. So on his next visit, he will get an oral surgery consult in addition to having sealants placed and a PAN taken.

R.A., Columbia University School of Dental Medicine

This afternoon I observed an orthognathic surgery consult in a high end practice. I was familiar with orthognathic surgery from Columbia’s emphasis on medicine and high reputation in oral and maxillofacial surgery. However this was the first time I had really witnessed a consultation for orthognathic surgery in a very practical setting.

A 28 year old female patient presented to the clinic because she was unhappy with her facial proportions. She had orthodontic treatment for 2 years prior, but was unhappy with her prominent upper lip, retruded lower lip, and also mentioned that she was unhappy with her nose being too wide (despite having a previous rhinoplasty).

Seeing this patient reinforced how important it is to take a good history of the patient. This patient in particular had a history of plastic surgery, included the rhinoplasty, so right away one has to be aware that she is going to be very particular about the results. Often patients like these change their minds, so even if the surgery gives her what she wants, she may be unhappy with it at a later point in time. It is important for the surgeon not to make guarantees, and to thoroughly advise the patient on their options.

The consulting surgeon was simply brilliant in the manner he conducted his consult. This oral surgeon is an attending at Columbia and I have met him before. However this was the first time I got to see the wealth of his knowledge in full action. He is a very powerful presence but he listened to the patient and all her needs and concerns. He then advised her on the possible options, however the patient was still adamant that she wanted to have her maxilla retruded. The oral surgeon was very honest with her and explained that women pay thousands of dollars to have her full look. He pointed out that if you retract the maxilla, the soft tissues will fall back as well, and she would lose that youthful look that she naturally has.

One of the most impressive parts of his consultation was that he was still very knowledgeable about general dentistry. He took two sets of impressions and was very proficient at taking them for an oral surgeon!

He found two issues from his exam and consult:

1. Deficient mandible/class II skeletal discrepancy

2. Wide alar base

His best treatment plan at this point was mandibular advancement via BSSO (bilateral saggital split osteotomy) along with an alar cinch to address the patient’s issue with the width of her nose. The alar cinch procedure was an intriguing option and gave the patient an alternative to getting another rhinoplasty. He  explained to the patient that an oral surgeon can go intra-orally with the alar cinch procedure which is more effective and does not produce the scarring that is possible from a rhinoplasty performed by a plastic surgeon. He explained that plastic surgeons are limited in what they can do because they cannot work intra-orally.

The patient finally became convinced that it was not a good idea to touch the maxilla, and mandibular advancement was the best solution. The oral surgeon didn’t shoot her down right away, and he advised her to choose between the given choices. However he took it step by step, until the patient saw the benefits of a less invasive approach.

The patient would also have a consult with the orthodontist because she would probably need brief orthodontic treatment after the surgery to adjust the bite so it is properly aligned.

R.A., Columbia University School of Dental Medicine

Periodontal disease is a multifactoral problem, and cannot always be answered by the traditional methods of mechanical debridement (scaling and root planing) and periodontal surgery. Although in most cases,  debridement and improvement of oral hygiene can do wonders, unique cases always arise which leave periodontists baffled.  What happens when you have a 30 year old patient, with no radiographic calculus or significant plaque buildup but has severe bone loss and 8mm pockets? Clearly debridement of the pockets isn’t going to work. Understanding the microbiology of periodontal disease is of increasing importance to the general dentist and working with specialized labs is vital to the successful treatment of the disease.

The Oral Microbiology Testing Service (OMTS) at Temple University School of Dentistry was designed specifically to assist dentists with identifying and treating difficult cases of periodontal disease. It is one of only 4 state and federally-licensed clinical periodontal microbiology reference laboratories in the United States.

The process:

How do you get the culture?
The dentist should first use college pliers and a cotton pellet to wipe away supragingival plaque. Then a medium cotton point should be placed into about six different sites with the deepest periodontal probing depths. The cotton point should be left in for 5 to 10 seconds and then quickly placed in the culture medium, which is then sent to the lab.

Once the lab has the culture, they incubate and culture it. This is done in a one to two week period in a special chamber that replicates the conditions of the area of the mouth in which the bacteria grows.

After the culture is grown , it is examined by microbiologists and  the types of bacteria are identified. Then an antibiotic sensitivity test is performed on all the species of bacteria that were found. The pathogens were divided into groups depending on their known associations with periodontal disease. An acceptable critical % threshold level was given for each species of bacteria. The % of cultivable microbiota for each species from the sample was then compared against the given markers. For example if the acceptable threshold level for a certain species was 2.5% but the level found in this sample was 5.6% then the conclusion would be that there were elevated proportions of that species.

Antibiotic sensitivity tests were performed for 4 major antibiotics commonly used to treat periodontal pathogens. This bodes well for the patient because specific antibiotic therapy can be given to the patient in addition to dental treatment.

Clinical Scenario:
A patient presented to Dr. Dorfman’s office recently with severe periodontal disease and acute necrotizing ulcerative gingivitis (ANUG) on the lingual aspect of #27,28. The patient was treatment planned for 4 quadrant scaling and root planning,

The patient was previously treated with amoxicillin and metrodiazanole, two commonly prescribed antibiotics for periodontal pathogens. However, the lab results showed that many of the periodontal pathogens found were resistant to both antibiotics. The head of the lab at the OMTS suggested the use of Cipro to target the gram-negative bacteria that were found to be in significantly higher levels than expected.

R.A., Columbia University School of Dental Medicine

Today’s patient came in to have new zirconium crowns placed on #8 and #9.  Here is a summary of the patient’s previous relevant visits:

First visit – #6,7,8,9,10,11 prepped based upon lab models

Second visit – zirconium crowns placed for #6-11 with Nexus base clear. Patient requested darker shade – changed to A2.5 and canines to A3.0 with lab on same day

Third visit - patient feels #8,9 are too thick palatally. Pt informed that space at mesio-gingival margin can be closed

Fourth visit – crowns on #8,9 removed, slightly reprepped and new temp placed

The patient had signed a consent form before cementation, stating that the patient is happy with the try in and understands the consequences of changing their mind once the crowns have been cemented. However Dr. Dorfman was went out of his way to accommodate her and agreed to place new crowns on #8,9.

Today the new zirconium crowns for #8,9 were placed so the patient could see the new look. However she was still unhappy after the try in. She felt that it was still a bit thick palatally and also didn’t like the convergence of the teeth mesio gingivally. At another office, the crowns would have to be sent back to the lab and the patient recalled. However Dr. Dorfman called up his lab tech who showed up in minutes. He noted the changes the patient wanted and advised it would take a few hours.

The impression was taken with Impregum polyether impression material, using both light and heavy body. An anterior tray was filled with the polyether regular body and the light body was placed around crown preps. The lab technician said it was a good idea to blow air over the light body to prevent bubbles from forming. Once air had been blown all over the light body, another layer of light body was injected. Then the anterior tray was placed. The lab tech took his impression back to the lab to make the necessary adjustments.

The adjusted crowns had outstanding contours in the mesio-gingival area. The patient did still feel a slight thickness palatally so this was adjusted down. The crowns were then cemented on with Nexus Base Clear.

This experience really showed me the importance of always giving the highest standard of care, regardless of the circumstances. The patient clearly signed the waiver and knew once the crowns were cemented in, it would be difficult to make any changes. However, it’s clear from all my visits so far that Dr. Dorfman takes tremendous pride in the work he delivers to his patients. It is this reputation that he has build, which draws patients from all over the world to his office.

R.A., Columbia University School of Dental Medicine

This afternoon I viewed a patient who was in for an implant placement on #9. The 25 year old female had the tooth extracted over 10 years ago because the tooth would not erupt and was not able to be orthodontically erupted. Prior to the implant surgery a bacterial culture was taken because of a few severe localized pockets on select molars and premolars, which may be indicative of post-juvenile periodontitis. (See Image #1) The bacterial culture was taken by placing paper points into the facial and lingual sites of each deep pocket location for a few seconds, and then placed into the culture solution. The culture will be sent to an oral microbiology lab for testing and further treatment will be decided on then.

The patient received profound anesthesia prior to the implant placement. The size and location of the edentulous area indicated the use of a 3.5mm x 12mm implant in the area of #9. (See Image #2 and #3) Radiographs were taken to verify the placement and seating of the implant and healing abutment and sutures were placed to reapproximate the tissues for successful healing. The patient has been wearing a flipper for approximately 8 years and therefore the seating of the flipper post-surgery was confirmed and no adjustments were necessary.

N.S., New York University College of Dentistry

A 21 year old female presented as a first time patient to the dental office. Her chief complaint was she was unhappy with smile, specifically the position of teeth #6, 10 and 27. Both upper and lower arches were severely crowded. Another dentist had suggested braces as the only treatment but the patient absolutely refused it as a treatment option. It was explained that orthodontics was the best treatment option, but not the only one.

For teeth #6 and 10, alternative treatment options to address the patient’s chief complaint were crowns, veneers or cosmetic bondings. All benefits and risks were explained. The patient’s finances limited her options to cosmetic bonding. Due to the labial flare of #6 and 10, sculpting (reshaping) the teeth would require removal of a significant amount of tooth structure. This would lead to nerve exposure so root canal therapy was strongly planned.

On the lower arch tooth #27 was completely lingually displaced from the arch. There was no room for this tooth in the arch, so the only reasonable non-orthodontic treatment option was extraction of #27. On the day of the extraction the patient was anesthetized with 3.6cc of lidocaine, and the extraction was completed by an Oral Surgeon without complication. A simple chromic suture was placed to allow soft tissue approximation and healing by primary intention. The 1 week re-evaluation showed the area of #27 had epithelialized over the wound and healed properly. Treatment of the remaining minor crowding in the mandibular arch was not desired by the patient.

At the next visit, prophylactic root canal therapy on # 6 and 10 was completed by the endodontist. Tooth #6 was anesthetized with 1.7 cc Septocaine and isolated with rubber damn. Access was obtained, and the single canal found was instrumented to 25mm, obturated with gutta percha and cement, and temporized. Tooth #10 was anesthetized with 1.7 cc Septocaine and isolated with rubber damn. Access was obtained, and the single canal found was instrumented to 22mm, obturated with gutta percha and cement, and temporized.

During the following visit, bonding and sculpting of #6 and 10 began. Tooth #6 was completed by an NYU senior dental student, and tooth #10 was completed by a Columbia University senior dental student. No anesthesia was necessary, as the teeth were root canal treated. The temporary fillings on the lingual of #6 and 10 from endodontic access was removed and replaced with a permanent composite filling. The lingual surfaces were roughened with a bur to allow for better retention. Next, the labial surface of the teeth were etched, bonded and MIDLF surfaces were built incrementally with Herculite bonding shade A1. The facial surfaces of the teeth were sculpted, bringing the teeth back into the arch. The occlusion was adjusted as needed. The patient was satisfied with the cosmetic results.

During a followup visit the patient requested a few cosmetic adjustments. The facial surface of #10 was etched, bonded and built up with Herculite bonding shade A4 followed by a external layer of XL2 bonding cover shade. The final contours were sculpted and the occlusion was adjusted. The patient was satisfied with cosmetic results.

After acclimating to the cosmetic bonding on #10, the patient scheduled another visit for cosmetic bleaching of the surrounding teeth. The teeth were isolated with a liquid dam to protect the gingival tissue. Two rounds of bleaching at 10 minute intervals on both upper and lower arches were completed. Patient informed that some white spots are normal and will resolve with time as the color of the teeth settles. Patient was satisfied with the color. Tooth #6 facial composite bonding was adjusted to improve color and give uniformity to the facial surface. Tooth #6 was reduced 1mm facially, etched, bonded and 1mm increments of XL2 composite were added on the facial; Bonding was sculpted and the occlusion adjusted. Patient was satisfied with cosmetic result.

The patient was encouraged to return for any other dental work needed, regarding the cosmetic bonding done, or any future treatment. She was advised to avoid hard foods on teeth #6 and #10. In the future if financially possible, she was encouraged to have porcelain crowns placed on #6 and #10. She was very happy with the final outcome and less timid about smiling and showing off her new teeth. Overall the treatment was delivered in a satisfactory and timely manner.

N.D., New York University College of Dentistry

This afternoon I continued the treatment of a patient’s #3 PFM crown. The crown came back from the lab with a Kaitlyn Loop on the lingual side of it for floss to keep a better hold of the crown. The crown was tried in, margins and contacts were checked, and occlusion was adjusted. The patient was satisfied with the esthetics and fit of the crown and signed a consent form for final cementation. The crown was cemented in with RelyX cement and the Kaitlyn Loop was removed.

The patient then complained of a chipped filling on the lower left. The patient is not currently in any pain. Tooth #19 was examined and the restoration was chipped on the buccal portion of the occlusal surface. A periapical and bitewing radiograph was taken of tooth #19. A periapical pathology was seen on the mesial root as well as a widening of the periodontal ligament on the distal root. Caries was found on the distal portion of the tooth. There is a possible fracture on the mesial root. The patient was given the information and treatment options and will return at the next visit to further explore the treatment options for this tooth.

N.S., New York University College of Dentistry