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

A 32 year old Caucasian male presented with the chief complaint, “I want to fix my smile.” The patient complained of hot and cold sensitivity as well as swollen, bleeding gums after brushing.

Past Medical History: The patient is not on any medication and has no known allergies to food or medications. The patient also denied using any illicit drugs.

This patient had very limited funds to have his mouth fully rehabilitated. However, several treatment options were discussed with the patient which include:

# Extraction of the non restorable teeth
# Root canal therapy, cast gold post and core with final crown restoration of restorable teeth
# Composite restorations
# Crowns and bridges

However, the patient could not afford the treatment options provided. Based on this, a maxillary round-house provisional restoration was agreed upon. This was treatment planned; however the poor prognosis of some teeth was largely noted. The patient was solely concerned about his esthetic look, hence requested that only the maxillary arch be treated. Appropriate consent forms and treatment plans were signed prior to any rendered treatment.

Treatment Procedure
A maxillary local infiltration with Carbocaine was performed. Extraction of teeth #s 2, 5, 12 and 15 was also performed and hemostasis was achieved through the placement of sutures.

Peripheral wax was adapted over the maxillary arch area where the patient had worn-out teeth. An upper alginate impression was taken to serve as a matrix for the provisional restorations. Gross crown preparation reductions were done on all existing maxillary teeth with the exception of tooth #4 and #13 which were used to achieve occlusal stops to maintain the patient’s vertical dimension of occlusion.

With the use of the previously taken alginate impression matrix, Luxatemp was used as the temporary restorative material. This was injected into the alginate matrix and then re-seated on top of the prepared teeth. The temporary round-house restoration was taken out of the patient’s mouth and was trimmed and recontoured to proper shapes and sizes. It was then tried-in and final adjustments were made for the margins and contour. The occlusion was checked and then cemented temporarily into patient’s mouth. The patient was pleased with the work completed. From start to finish, the entire treatment procedure took approximately two hours.

Although, this was not the most beneficiary dental procedure that could have been rendered, considering the patient’s limited finances and his desire to look esthetically presentable, this was the best treatment that could have been provided at that moment. The patient was well informed about possible sensitivity following this treatment as well poor long term prognosis of some existing teeth.

Another option for treatment could have been extraction of all maxillary teeth and subsequent fabrication of an upper maxillary complete denture. The denture could have been implant supported to enhance stability and function of the denture. But this would have cost much more money that the patient could not afford.

Apart from rendering quality care to patients like this, a thorough dental and social history should be elicited from patients so that the etiology or possible risk factors causing such rampant nature of the disease be identified and addressed. This constitutes part of the treatment options. If this is not addressed, no matter the treatment rendered, it will surely fail. Good oral hygiene instructions should be given and frequent recall appointments given to such patients.

O.O., New York University College of Dentistry

Before any dental treatment is commenced in this office, various treatment alternatives are presented to a patient with accompanying merits and demerits as well as long term prognosis of each of the treatment plans discussed. It is then left to the patient to decide which he or she prefers based on his or her financial state or medical/health related reasons. In some cases, the office may give a courtesy discount to the patient or render some of the treatments absolutely free especially if they are going to be treated by dental students under close supervision. If all is agreed upon, the patient is asked to sign the treatment plan as well as a consent form authorizing commencement of treatment.

A middle-age male patient presents to the practice with a fractured broken distobuccal cusp of tooth #18. The tooth has been previously restored with an occlusal amalgam dental filling many years ago. The patient complained of tooth pain sensitivity to cold drinks which was transient and disappeared on removal of the stimulus.

Past Medical History – Patient has a history of Asthma. An episode of Epilepsy occurred about 20 years ago.
Drug History –Ventolin, Advair and Theodur
Social History – Patient currently uses tobacco and is a social drinker – his head and neck were within normal limits during an oral cancer screening.

A periapical x-ray of tooth #18 revealed a slight radiolucency underneath the distal portion of the existing silver filling restoration. All other findings were within normal limits radiographically. Clinically, there was a distal marginal ridge and part of the distobuccal cusp fracture. Treatment options for this tooth included removing the old amalgam restoration, examining and re-evaluating it to see, if it could be re-restored with a filling. The patient was also informed that the tooth might need root canal therapy and final dental crown restoration. This was explained to the patient and all questions were entertained and answered by Dr. Dorfman. This constitutes part of the treatment plan and consent and was signed accordingly.

I was instructed by Dr. Dorfman to remove the amalgam filling, which I did. Following removal of the amalgam, it was confirmed that there wasn’t enough tooth structure left, the little left was unsupported. The patient agreed to placement of a dental crown as previously discussed. A little recurrent tooth decay was found clinically and this was removed. With these findings, the tooth wasn’t a good candidate for a regular restoration tooth bonding dental filling.

A supragingival circumferential shoulder preparation was performed as well as an adequate occlusal reduction. The purpose of the supragingival preparation was to enhance patient’s ability to keep the crown margins clean since this was a non esthetic zone. For aesthetic zones like the maxillary anterior teeth, an infragingival preparation would be ideal but bearing in mind not to violate the biological width. This can cause periodontal complications like gingival recession that would further make it non esthetic.

To also enhance retention on the preparation a small groove was created on the buccal aspect of the tooth. Final impressions included using impregum on a full arch tray, an alginate counter model impression of the maxillary arch, and a bite registration so an excellent occlusal contact can be achieved following the final fabrication of the crown by the dental laboratory. Another way to take a final impression is through the use of a triple tray but this was not used here since the prepared tooth was the most distal in the dental arch. Tooth shade selection was also performed.

A provisional tooth was created with an acrylic resin using the block technique. In doing this, acrylic resin is mixed until it reaches the dough stage. This is then adapted to the prepared tooth and the patient is asked to close on it in the centric occlusion. This is taken out and re-seated continuously so as to record the margins of the preparation. It is then trimmed into the shape of a tooth and possibly relined to get better marginal fit. Contacts and occlusion are also checked and finally cemented using temporary cement.

Two weeks later, a finished PFM dental crown was returned from the dental laboratory. This was shown to the patient before cementation. The temporary dental crown was removed using a crown remover and the temporary cement was cleaned out from the prepared tooth. The permanent crown had a Kaitlyn loop attached to the lingual metal collar onto which dental floss was attached to prevent possible aspiration during try-in. Crown try-in was done in the mouth. Contact was checked first followed by a check of the margins. A periapical X-ray was taken to see the interproximal margins and fit. The crown was removed and prepared tooth’s surface and was ready for permanent cementation. In this office, Rely-X cement is used. This comes as a powder and liquid which allows the doctor to create a preferred consistency. This is mixed on a mixing pad until the proper consistency is created. It is highly recommended that tooth is dried and isolated using cotton rolls and gauze. A small amount of Vaseline is applied to the outside of the crown to prevent the dental cement from adhering to the porcelain tooth crown.

The cement was applied to the internal surface of the crown and sat gently over the prepared tooth. The patient was then asked to bite on cotton roll placed on the occlusal surface of the crown to allow for adequate seating for about 10-12 minutes. All excess dental cement was removed from the margins. The occlusion was checked and the lingual floss holding loop was removed using a high speed with a diamond bur.

O.O, 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