Today’s experiences encompassed the evaluation and editing of a complex treatment plan. The patient is a 57 year old female patient who is extremely phobic in the dental setting. Her past medical history includes smoking 1 pack per day, sinus problems, migraines, and dental phobia. Her chief complaint was that she wanted her top teeth fixed for her son’s wedding this upcoming summer.

The patient’s dental phobia is a major contributor in the execution of her dental care. Her dental phobia is so severe that she sent her husband to the first few visits to take care of the treatment planning instead of personally being there, and, due to past dental related trauma, when she is in the dental office she cries. She would like the treatment done all in one day and under IV sedation so that she can get it done as quickly and as painlessly as possible.

The patient would only like to focus on the upper arch at this time. She has #4-11, 13, and 14. She is missing #1-3, 12, 15, and 16. The patient has periodontal disease which could be classified as moderate to severe chronic generalized periodontitis, evidenced by photographs and radiographs. (Figure 1)

Figure 1. The moderate to severe chronic generalized periodontal disease is evident in this radiograph. Notice the low bone height on both the maxilla and the mandible.

Therefore, initial scaling and root planing of the upper arch is indicated. Although the patient also has the disease on the lower, the patient would only like to focus on the upper arch and the dentist would like to avoid any sensitivity on the lower arch. Because the patient is afraid of any possible pain from her dental work, endodontic therapy was suggested in all of the upper teeth to avoid the pain. On most of the teeth the endodontic therapy is not indicated for carious or disease related reasons, but primarily to avoid any post-operative pain.

After the periodontal and endodontic therapy is done, the planned restorations will be prepared and inserted. There will be crowns on #4, 5, 13, and 14 and there will be resin veneers on #6-11. The crowns will only be temporary since the patient would only like to come in for 1 visit. The temporaries will be placed under a condition that the patient will come back for final crown insertion within 6 months of this treatment. The veneers will be resin because the patient does not want to come back for another visit, which would be necessary if porcelain veneers were fabricated. The patient was informed that resin veneers are not as strong or long lasting as porcelain veneers.

In addition to the aesthetic work which will be done on the maxilla, there is also a concern of a red lesion on the hard palate. Since the patient smokes 1 pack per day, this puts her at a higher risk for oral cancer. The oral surgeon will examine and possibly biopsy the lesion during the visit. (Figure 2)

Figure 2.  The red lesion on the palate is of concern, especially since the patient is a smoker. An oral surgeon will examine and possibly biopsy the lesion.

All of this therapy will be done in one visit in order to comprehensively deal with the patient’s phobia of dentistry and pain. In addition, since the husband is the primary person involved in the treatment planning process, both the husband and the patient will sign the treatment plan, confirming that they both understand and agree to the treatment outlined.

Lateral, front, and occlusal views of the maxilla before treatment.

N.S., New York University College of Dentistry

Today I observed a cementation of a gold post and core of tooth #7, a shoulder preparation, fabrication of a temporary pre-fabricated crown, final impression technique of the prepped tooth, and then observed the temporary cementation of the #7 pre-fab crown.  

Patient presented with a past root canal treatment done on #7, but had recently fallen, hitting her front teeth, especially # 7 and #8.  She was seen by an Oral Surgeon to make sure that there was no bone or facial fracture and was given a splint to keep her anterior teeth intact. 

I learned that there are different treatment options for this patient.  She could have extracted #7 and placed an implant, or extracted #7 and make a 3 unit bridge from #6 to #8, or do ortho to recline #7 and then prep it to make a PFM crown or an all ceramic crown.  Since the patient fell and could have fractured her root or crown of #7, ortho tx to move tooth would cause more fractures, so the prognosis would be poor; therefore, ortho treatment before crown prep would not be a treatment option.  

The observation first began by opening up the access of #7 by removing the temp filling with a bur. Then the gold post and core of #7 was inserted. The post was refined with a bur, then it was checked with occlude spray to observe for pressure/tight areas. Once the post and core fit adequately, then it was permanently cemented which took 12 minutes to cement.  Then a shoulder prep was done with a bur, made the margins clear and checked to see if the prep was tapered and not labially reduced, in another words made the prep slightly more lingual on the facial side.  Then I observed the selection process of a pre-fab #7 crown.  Once the pre-fab crown was chosen, the margins were reduced to make it fit the prepped tooth.  A mixture of monomer and acrylic was made and poured into the pre-fab crown, and then the crown was placed into the prepared tooth to get the internal fit of the pre-fab crown.  Then, the excess was removed around the margins.   

After that, I observed the final impression of #7 prepped tooth.   Since the patient has existing porcelain veneers on her anterior teeth, it’s a good technique to put Vaseline on the veneers and to block out the embrasures with wax, so that when the impression is taken and then removed, there is no chance of her other porcelain veneers coming out.  I learned how to analyze an impression to see if the margins came out or not.  I observed the selection of the final shade of the porcelain crown which was B1. A Polaroid film was taken, so that the lab could match the correct shade. Then, the pre-fab temp crown was refined with a mixture of monomer and acrylic and the excess was removed with a bur.  Finally, once the fit was adequate, then the pre-fab temp crown was cemented with temporary cement.  I also observed the bite registration technique; the registration of the anterior incisors where taken so that the lab has the patient’s occlusion which helps with the fabrication of the porcelain crown.  Then the lower anterior incisal impression was taken with alginate, so that the lab could pour up a lower anterior cast as a guide to make the porcelain crown and check the occlusion. 

In conclusion, today’s observation was a great learning experience.  I learned that we should never put Vaseline on the prepped tooth to get the internal fit of the pre-fab crown because it could contaminate the cements.  Also, I learned that it’s more efficient to fabricate the temp crown before taking the final impression of the prepped tooth. 

G.Y., New York University College of Dentistry, Observation 1

Last Monday was a very educational and rewarding experience. I observed many procedures done by different specialists.

The first one that I participated in was Phase I Therapy of single implant placement on a middle-aged male patient. The surgery was done by an oral surgeon. He used an approach of first creating a flap to help visualize the path of implant insertion. I asked him afterwards whether there was a specific reason that he created a flap first instead of directly “drilling into bone”, and he said there wasn’t, except for the fact as I mentioned to enhance visibility (good reason for me if it means implant will be placed correctly). I was able to see on the x-ray the alignment of the placed implant, and according to my still limited knowledge, it was excellently positioned.

The treatment of the same patient was continued by the general dentist who cemented a temporary bridge in area where implant was placed.

In another treatment, the endodontist performed a root canal therapy on the mandibular molar of another patient. She demonstrated the lateral condensation technique when obturating all 3 canals. This time I saw her using an apex locator, a great device which as she explained showed her the apex both radiographically and clinically. She told me that it is the best to stay within 0.5 mm around the apex when placing master cone with the cement, because that will prevent excessive widening of the apex and perforation of the canal. Upon completion of the RCT I saw the final radiograph, which again showed a very successful end result.

After RCT, the patient was transferred to a different room, where the treatment continued with the core buildup and crown prep done by the general dentist. The patient did not need post and core placements because there was enough tooth structure to ensure longevity of the fixed restoration with the composite core. The finish line of the crown prep was a combination of shoulder with bevel and chamfer, done as such to avoid unnecessary compromise of the tooth structure. After the final impression and shade selection, a temporary crown (constructed at the chair-side via “block technique”) was cemented and patient was dismissed.

Throughout the entire time, what was most apparent in the office was the nature of the comprehensive and personalized treatment, excellent pain control and sensitivity to patient’s comfort. Interaction between Doctor and Patient was constant and conducted in comfortable yet respectful manner. The pain control was done not only during the procedure but also after the visit; because at the end of the treatment Dr Dorfman made sure the patient received post-op instructions and pain medication.

E.T., New York University College of Dentistry, Observation

This Wednesday was a great learning experience for me.  I had the opportunity to watch the Doctor perform a DO dental caries excavation on tooth #20; however, the caries was very extensive, and there was a pulp/nerve exposure. He then performed a direct pulp cap and bonded over it with composite to complete the restoration, and informed the patient of the possibility of future root canal therapy on that tooth. So I will never forget what a direct, or indirect, pulp capping procedure entails, I did some research on the topic:

Vital pulp capping is a controversial procedure as many clinicians are uncertain of the long-term success when compared to the proven long-term success of root canal therapy.  Vital pulp capping basically entails dressing exposed pulp to maintain vitality.

For success, the tooth should be asymptomatic and have bleeding controlled. 

There are basically two techniques.  First the area is disinfected and then calcium hydroxide placed directly on the pulp.  Then the calcium hydroxide should be covered with RMGI or zinc oxide eugenol then dentin bonding agent and permanent restoration placed.  The second technique involves total acid etching the cavity preparation created with 32% phosphoric acid then dentin bonding agent and a few layers of primer followed by RMGI and a permanent restoration. 

M.C., New York University College of Dentistry, Observation

The result of the direct pulp cap mostly depends on ability of dentist and capping material to prevent microbial leakage. 

Indirect pulp capping is a procedure performed when a dentist comes close to the nerve/pulp when excavating caries, but there is no penetration or exposure.  This is done to stimulate reparative dentin formation and prevent the need for root canal therapy

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

This turned out to be a great day for me because I learned many new things about endodontics and the different technologies that they have at their disposal.

The endodontist was telling me about D-MTA, which is a substance that contains tetracycline and a few other chemicals in it. It can clean the canal and kill the bacteria and works very quickly so you don’t need to pack the canal with CaOH and send the patient home to do the obturation a week later. With this product it is possible to clean and obturate all in the same visit. She also taught me about the different ways that gutta-percha can be melted and packed into the canal so it is easy to reach lateral and accessory canals and that reduces the incidents of retreats.

She taught me how products are compared and how different solvents and products are tested: The test involves packing the canal and checking for how much of a substance can pass through, thereby testing the seal. It was interesting to see how well she was able to laterally condense the gutta-percha without using too much cement. One of the roots had a bifurcation right near the apex and that had to be repacked and it was interesting to learn how that was done.

I also learned how the apex locator was used specially in conjunction with regular endo files as a self check. The patient had come from another country and was seeking full mouth reconstruction over the course of the next few years in multiple phases. This visit was focused on extractions and endo procedures in order to preserve teeth and allow for healing of extraction sites so that implants could be placed.

H.A., New York University College of Dentistry, Observation

The second dental patient that I observed was a Wall Street executive. The patient was extremely nervous and agitated to the point where his hands and lips were quivering. The patient was frequently given verbal comfort either by Dr. Dorfman or the endodontist who was treating him. His oral problems were overwhelming. Due to tooth erosions and cavitations, he had a collapsed bite; therefore, prior to any reconstructive dental work, he had a TMJ consult. On the day of the appointment, the patient was scheduled for 8 RCTs (root canal therapy) which were completed within 2 hours to minimize the patient’s stress level. After the RCTs were finished, impressions for gold posts and cores were taken and sent immediately to the dental lab via a messenger. The patient will have his temporary bridge #6 to #11 made in lab and occlusions restored on Friday.

Click pictures for more information.

P.B., New York University College of Dentistry, Patient 2

The first patient was a 31 year old male that presented to Dr. Dorfman’s office with severe cavitated lesions in the anterior region due to bulimia. This patient was very fearful of dentists and always came only for emergencies. In order to ease his nervousness, the patient was given nitrous oxide and soon became relaxed and ready for treatment.

In his treatment plan, he had 6 RCT’s and gold posts and cores. The patient’s initial visit was 5 months ago at which time root canals were done and temporary restorations were made out for luxatemp. During today’s visit (Monday) patient 6 posts and cores cemented and fixed temporary restorations. Posts and cores were adjusted prior to insertion and cementation. Handling was enhanced by having Kaitlyn Loops that were taken off after cementation. On Wednesday, two days later, he will get temporaries that were fabricated in the lab and as soon as next week he will get his final porcelain crowns.

P.B., New York University College of Dentistry, Patient 1