I had lunch last week with my friend, Dr. H Jinder Khurana, a retired New York City periodontist (gum specialist). It would be nice if our teaching program at The Center for Special Dentistry could offer emeritus professors of dentistry a place to spend part of a day and teach our students.

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

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

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

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