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The Economy Is Still On Its Knees, Yet This Periodontal Start-Up Stands Tall

Patrick — Wed, 17 Apr 2019 17:51:30 +0000

With commercial rents still high and professional space hard to find in New York City, Central Park Periodontics has defied current market trends by creating a full-service periodontal practice that specializes in dental implants, the treatment of periodontal disease, and laser gum surgery. It has done so with a rare blend of an experienced clinician and three associates.

Central Park Periodontics is unique by launching a new dental practice in this economy. And more so because it specializes in periodontics, implants and laser gum surgery.

Why create a new dental practice in the midst of troubled economic times? “The city was ripe for a periodontal practice that caters more to the individual needs of each patient than to a by-the-book-formulaic approach to patients,” says founder and president, Dr. Alan A. Winter, who is a board-certified Diplomate of the American Board of Periodontology. “Every patient is different and every clinical periodontal and dental problem can be handled by more than one modality.” Dr. Winter went on to say, “While periodontal surgery is effective when needed, it is not the only way to treat gum disease. Improved oral hygiene, effective root planing and scaling, and laser gum treatments can also be effective treatment modalities for bleeding gums and periodontal pockets.”

How else does Central Park Periodontics blend new technologies with its unique brand of personalized periodontal and dental implant treatments? They utilize state-of-the art digital X-rays that reduce radiation to a minimum; have evolved into a “green” practice by eliminating most forms of paper and charts, and embrace technologies such as electronic submission of insurance forms, contacting patients via email or texting, and posting the New Patient Health Questionnaire that can be completed on their website in order to save time during that first office visit.

But being a new practice, does not mean that the periodontists of Central Park Periodontics are fresh out of school or inexperienced at performing complex periodontal surgeries, inserting endosseous dental implants, treating root recessions with gum grafts and more. Founded by Dr. Alan A. Winter, Central Park Periodontics blends his more than three decades of dental experiences as a clinician, teacher, scientific writer, and lecturer with his younger associates, Drs. Samantha Aaron, Navid Baradarian, and Julia Sivitz, who are highly trained in osseointegration, sinus grafts, and the best ways to approach the complex links of periodontal disease with systemic diseases such as heart disease or strokes.

Central Park Periodontics was created in a series of bold moves. “I went to fifty periodontal practices over the course of one year,” says Tufts Dental School graduate, Dr. Julia Sivitz, “and no one would offer me a job.” Likewise, Dr. Samantha Aaron – a graduate of NYU’s dental college – interviewed at a number of established periodontal practices that yielded the same result: no job offer. Dr. Navid Baradarian’s story differs in that he received extra training in a general dental residency and then practiced family dentistry for a year before returning to dental school to earn his periodontal certificate from UMDNJ (the University of Medicine and Dentistry of New Jersey). His experience taught him to seize and opportunity and he did so by buying a small periodontal practice in Brooklyn. “For me, though, I always wanted to practice periodontics in Manhattan and Central Park Periodontics offers me that opportunity.”

The blend of young and old makes Central Park Periodontics special. In this economic environment, like many others, dentists find they need to tighten their belts and delay retirement by practicing longer. The last thing they would consider is to create a new office let alone take in three associates at the same time. Yet that is just what Dr. Alan A. Winter has done. “Young dentists bring new skill sets and energies to a practice,” says Dr. Winter. “I needed to a create a periodontal practice that would cater to the special dental needs of the boomers because of the strong evidence linking untreated gum problems with systemic diseases and at the same time, bring in talented associates skilled in treating the cosmetic periodontal needs of today’s younger generation.”

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Periodontal (Gum) Disease and Laser Gum Surgery

Patrick — Wed, 17 Apr 2019 17:27:25 +0000

Is gum disease common?

If you’ve been told you have periodontal (gum) disease, you're not alone. An estimated 80 percent of American adults currently have some form of the disease. Periodontal diseases range from simple gum inflammation to serious damage to the soft tissue and bone that support the teeth. Untreated, gum disease can progress to the point that teeth need to be removed. Gum disease is the major cause of tooth loss in adults.

Gum disease is a threat to your oral health. Research points to the possible health effects of periodontal diseases that go well beyond your mouth, and may be linked to other systemic conditions. Whether gum disease is stopped, slowed down, or gets worse depends a great deal on how well you practice oral hygiene ad care for your teeth and gums daily, as well as with the assistance and treatment by dental professionals, you dentist and his/her dental hygienist.

What are the symptoms of gum disease?

Here are the most common symptoms of gum disease. If you have any of these, you should consult your dentist about the health of your gums and teeth.

● Red, swollen, or tender gums

● Bleeding while brushing, flossing, or when eating hard food

● Receding gums that pull away from the teeth that cause teeth to look longer than before

● Loose teeth

● New spaces forming between teeth at the gum line, often trapping food

● Spreading of teeth that once touched one to the other

● Persistent bad breath (halitosis)

● A change in the way your teeth fit together when you bite

● Bone loss noted on dental X-rays

● Gum pockets greater than 3 millimeters

If you have gum disease, can a laser (LANAP) gum procedure help your condition?

In most instances, laser (LANAP) gum procedures can help patients diagnosed with gum disease. While Dr. Winter, who is a board-certified periodontist, does perform traditional periodontal procedures such as flap surgery, osseous surgery, bone grafts, dental implants, gum grafts and more, as a result of his special training, he is certified to offer LASER therapy as an alternative to other conventional forms of gum treatment. The LANAP procedure can successfully be performed on patients with diabetes, patients on aspirin therapy, patients who take blood-thinners such as Coumadin or Plavix, patients with osteoporosis, patients on bisphosphonates such as Fosamax, Boniva, Actonel, Reclast and as well as other medical conditions. If you’ve been told you would benefit from gum surgery, then LASER therapy is certainly an option to consider, and it is an option that is simple to perform and comfortable for the patient.

The LANAP utilizes a tiny beam of LASER energy to treat moderate to severe periodontal disease. This LASER light gently removes harmful bacteria and diseased tissue from the gum pocket. In effect, it sterilizes both the infected pocket and the tooth root. Sterilizing the hard outer shell of the tooth root, known as cementum, is critical to the success of the LANAP because endotoxins that are secreted by harmful bacterial pathogens become embedded into the root surface. This process is more thorough and effective than the traditional scraping of the roots commonly referred to as scaling or root planning. This insures the best opportunity to remove the endotoxins so the tissues in the pocket have an opportunity to regenerate.

Clinical example

The image on the left is the before X-ray. It depicts severe bone loss characterized by a darker gray between two incisors (lower front teeth). This darkness means less bone is present. At examination, the gum pocket was 10 mm deep. (Pockets cannot be seen on X-rays). Treatment options for this problem included removing the tooth, performing gum surgery and inserting a bone graft while using a guided tissue membrane, or treating the gum pocket with a laser. A laser gum surgery was performed and the X-ray on the right is a 3-month followup. It demonstrates that the dark bone is becoming lighter in color; this translates to the fact that new bone is forming. This area will be monitored in the coming months and years, but at the present time, the residual pocket is healthy and only measures 1 mm in depth.

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Dental 3D Cone Beam CT Imaging: Part III Bifid Canals (and other deviations) of Inferior Alveoloar Nerve (Pre-surgical analysis for the insertion of dental implants)

Patrick — Wed, 17 Apr 2019 15:55:41 +0000

Dental cone beam 3D CT scans enable dentists to view anatomic structures not easily seen on 2D dental x-rays, including bifid mandibular canals, which is a common variation of the mandibular canal. The mandibular canal may split along different positions of the mandibular nerve; one branch may be smaller than the other (1-2). Langlais et al reported a 0.95% prevalence of bifid mandibular canals (3) while Sanchis (4) reported an incidence of bifid nerves as 0.4%, finding 7 out of 2012 mandibles that were studied. Many authors have investigated the incidence of bifid canals using panoramic or CT 3D images or both, and have concluded that while uncommon, they need to be identified when surgical procedures, such as removal of impacted third molars, insertion of dental implants in NYC, and osteotomies, are to be performed (5 – 9).

Once multiple (bifid) canals are identified, the local anesthetic injection technique, prosthetic design, and surgical procedures can need to be modified to prevent pain and discomfort during treatment procedures (10) in order to insure better outcomes.

The purpose of this study was to identify the incidence of bifid and/or multiple branches emanating from the inferior alveolar canal in 500 consecutive patients needing dental implants in NYC using cone beam 3D CT imaging .

Methods and Materials

CT scans of the dental arches from five hundred (500) consecutive patients taken in nine (9) centers located in three (3) states were uploaded to the main processing center of a single dental radiological practice (i-dontics, llc., New York, N.Y.), which is limited to taking and processing 3D CT images for the dental community. Scans were taken on either i-CAT scanners (8 centers) or on a (1) NewTom 3G scanner. All studies pertaining to gum disease in New York City were converted to SimPlant (Materialise, Glen Burnie, MD). When not specified, the data was converted to SimPlant version 10.

In Part I of the cone beam 3D CT study, the following parameters were recorded for each patient: age, gender, reason for the CT scan, which dental arch was to be studied, the format for the delivery of the data, and whether or not a radiographic guide was used. These results were published in Part I of the study. Parameters relative to the prevalence, location, and diameter of the lingual artery were measured and reported in Part II. The value and relevance of 3D imaging was also discussed in this paper.

In this study, Part III, the incidence of bifid nerves of the inferior alveolar canal were recorded by viewing images from a 3D dental cone beam CT scan. The position of the second canal was noted and listed as posterior to the teeth, within the body of the mandible but posterior to the mental foramen, coincident with the mental foramen, or anterior to the mental foramen. Multiple branches (more than two) were identified and recorded.

All CT studies were made into 1.0 mm slides and viewed both in the coronal and transaxial planes. To be counted as a bifid canal, each offshoot had to be continuous with the main inferior alveolar canal in each slice. For consistency, all CT studies were examined for bifid or multiple branches that were offshoots of the inferior alveolar canal by one examiner. A proper CT investigation is essential for perfect diagnosis of gum disease in NYC.

Results

Two hundred and ninety-six (296) mandibles were included in this 3D CT dental cone beam study. Of these, 186 patients or nearly sixty-three percent (62.84%) did not demonstrate evidence of a bifid canal. In contrast, 110 patients or more than thirty-seven percent (37.16%) had one or more bifid canals.

Figure 1. Nearly 63% of the mandibles studied did not have evidence of a bifid canal. However, 37,16% of the patients had one or more bifid canals.

Of the 110 patients demonstrating bifid canals, 56 or 50.9% had one bifid canal. Two bifid canals, as noted on CT scans, were demonstrated in 37 or 33.6% of the mandibles and 17 or 15.45% had three or more canals.

Figure 2. Of the mandibles demonstrating a bifid canal, more than half (50.9%) had one canal, while 33.6% had two canals and 15.45% had three or more canals.

Fifty-five (55.45%) of bifid canals were unilateral. Two thirds (67%) of the unilateral bifid canals were on the right side of the mandible; one third (33%) of the unilateral bifid canals were on the left side of the mandible. Nearly 46% (45.55) of the bifid canals were bilateral. These findings determined by viewing 3D CT images.

Figure 3. Fifty-five percent of the bifid canals were unilateral while nearly 46% were identified bilaterally.

In addition to identifying if a bifid canal was present, if it was in only the right or left side of the mandible or if they were bilateral, the location of each bifid canal was noted in the following manner: did it end at the mental foramen, posterior to mental foramen, or continue anterior to the mental foramen. Nine (9) bifid canals (8.18%) ended at the mental foramen, 94 or 85.45% ended posterior to the mental foramen and 7 or 6.36% continued anterior to the mental foramen.

Figure 4. The majority of the bifid canals (85%) ended posterior to the mental foramen, with 8 percent ending at the mental foramen and 6% extending beyond (anterior) the mental foramen.

Discussion

The relative incidence of bifid canals has been reported as less than 1% (3,4) of all gum disease in NYC, while it has been shown that the split of the mandibular nerve may be of unequal sizes (1,2). Regardless of the frequency of identifying bifid canals, various authors have identified the surgical risks and complications that may be experienced when they are encountered, including an inability to obtain profound anesthesia using a local anesthetic (5-9), injury from NYC dental implants, removing impacted wisdom eeth, and more.

In order to achieve standardization and consistency, the authors agreed as to what constitutes a bifid canal as identified on the 3D image: any branch that appeared as a continuous radiolucent canal extending from the inferior alveolar nerve. All 3D CT slices were 1mm in thickness and all bifid canals were viewed and appeared to emanate from the IAN in three planes: axial, coronal, and sagittal. Once the parameters were defined, one researcher examined and identified all of the bifid canals noted in this study, which were then verified by a second author.

Based on these parameters, the incidence of identifying bifid canals in this study was greater than in previously reported studies: 37%. The concept of bi- means “two,” and bifid means forked or cleft. While the purpose of this CT cone beam study in NYC gum disease was to identify the incidence of bifid canals, more than two canals of the IAN were identified in 17 patients or 15.45% of the cases. In most instances, 3 branches were identified; in one case, 8 branches were identified.

A relative few bifid canals ended at the mental foramen or extended anterior to it: 16 patients in total, or 14.54%. More than 85% of the bifid nerves identified in this study, as determined by 3D CT cone beam images, ended posterior to the mental foramen.

The significance of the findings in this study matters relative to the size and location of the bifid canals, and what clinical procedure is anticipated being performed. When it comes to operative dentistry, it has been postulated that bifid nerves may explain why anesthesia is not as profound as it should be when employing a local anesthetic. When encountered, infiltration of the local anesthetic to anesthetize these extra branches of the IAN may help achieve greater local anesthesia.

When planning New York City dental implants surgery, it is helpful to identify if bifid canals exist in the surgical site. Encountering these extra canals may not only contribute to unwanted local paresthesias of the gingival that these aberrant nerve branches may serve, but may explain unusual bleeding that emanates from the alveolar bone (10-11) during periodontal osseous or dental implant surgeries.

Figures 5 and 6 illustrate an example of multiple canals as they were identified in this study of gum disease in New York. While the widest branch, which is anterior to tooth #18, is evident on the panoramic slice, smaller canals are highlighted in Figure 6. Note the arrow in Figure 5 that highlights another bifid canal. Careful inspection will note additional canals emanating from the right IAN.

Figure 5. Arrow indicates a small bifid canal that starts and ends distal to tooth #31. A larger canal can be seen anterior to tooth #18.

Figure 6. The canal is highlighted in red, illustrating 3 bifid canals.

Mention must be made of the value of 3D images identifying normal and abnormal structures when compared to 2D images.

Figure 7 is a panoramic image (formatted in a 15 mm trough) taken on a patient that was referred to the CT lab after an implant was inserted that resulted in paresthesia in the patient.

Figure 7. Patient presented after an implanted was inserted in the #30 site resulting in paresthesia.

Figure 8 highlights a bifid branch of the IAN that was traumatized by the implant. This aberrant branch was not evident in the panoramic view due to the dense cortical bone. Traditional 2D imaging – both panoramic or periapical film – is limited in revealing key anatomic structures that are obscured by thick buccal and/or lingual bone. In this example, using 3D imaging prior to implant insertion would have identified the bifid (aberrant) branch and altered the surgical site.

Figure 8. A bifid nerve rises from the IAN and was traumatized by the implant insertion.

It is suggested that more studies be undertaken to identify bifid canals and their clinical significance.

Conclusion

Utilizing 3D cone beam CT scanning images, this study identified bifid canals in 110 out of 296 patients. The incidence (37%) was greater than reported in other studies. The clinical implications of bifid canals were discussed, as well as an appreciation for the value of utilizing 3D CT cone beam scanners when possibly considering dental implants in New York City.

Acknowledgements: Support for this study was generously given by Nobel Biocare AB Gothenberg, Sweden (Grant 2006-492) and Imaging Sciences Inc., Hatfield, PA.

References:

1. Mardini S, Gohel A. Exploring the Mandibular Canal in 3 Dimensions.

An Overview of Frequently Encountered Variations in Canal Anatomy. AADMRT Newsletter, Fall 2008.

2. Jacobs R, Mraiwa N, vanSteenberghe D, Gijbels F, Quirynen M. Appearance, location, course, and morphology of the mandibular incisive canal: an assessment on spiral CT scan. Dentomaxillofacial Radiology 31:322-327, 2002.

3. Langlais RP, Broadus R, Glass B. Bifid mandibular canals in panoramic radiographs. Journal of the American Dental Association 110:923-926, 1985.

4. ] Sanchis JM, Penarrocha M, Soler F. Bifid mandibular canal. J. Oral Maxillofac. Surg. 61: 422–424, 2003.

5. Rouas P, Nancy J, Bar D. Identification of double mandibular canals: literature review and three case reports with CT scans and cone beam CT. Dentomaxillofacial Radiology 36:34-38, 2007

6. Naitoh M, Hiraiwa Y, Aimiya H, Gotoh M, Ariji Y, Izumi M, Kurita K, Ariji E.

Bifid Mandibular Canal in Japanese. Clinical Science and Techniques Implant Dentistry. 16:24-32, 2007.

7. Claeys V, Wackens G. Bifid mandibular canal: literature review and case report. Dentomaxillofacial Radiology 34, 55-58, 2005.

8. Auluck A, Ahsan A, Pai KM, Shetty C. Anatomical variations in developing mandibular nerve canal: a report of three cases. Neuroanatomy; 4: 28–30, 2005.

9. Dario LJ. Implant placement above a bifurcated mandibular canal: A case report. Implant Dent 11: 258-261, 2002.

10. Auluck A, Ahsan A, Pai KM, Mupparapu M. Multiple mandibular nerve canals: Radiographic observations and clinical relevance. Report of 6 cases. Quintessence International. 38:781-787, 2007.

11. Winter AA. Bleeding from a Nutrient Canal: A Case Report. NY State Dent J 46:646, 1980.

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