Top Dentists 2007: Smile

Robert Penna
Photographs by Tom Nutter
www.tomnutterphotos.com

 

Dentistry is better than ever. That means your crooked smile can be easily corrected with invisible appliances and root canals can
be performed without causing you a moment of pain.
Following, interviews with the dentists who do dentistry best.

  (Note: The dentists profiled received the greatest number of nominations from their professional peers. Many excellent practitioners are not profiled. Their exclusion should not diminish their fine reputations.)

 

 

Orthodontics Robert Penna
When Robert Penna was a freshman at Archmere Academy in 1980, his friends wore braces bound with steel bands and rigid separators between each tooth. Just the thought of those metal devices still makes him cringe.

“Extremely painful,” he says.

Thanks to Penna’s precision, and a few new appliances, those memories become more distant every day.

Penna straightens the teeth of patients from 6 to 80 years old from the Medical Arts Pavilion at Christiana Hospital. Corrections to tooth alignment are far more than aesthetic, however. Bad alignments and crooked teeth can cause several problems. For those who need Penna’s help, the days of stainless steel braces and aching teeth are, fortunately, gone, he says.

“It’s a cool time to be an orthodontist because the technology is ever evolving,” Penna says. “The curve over just the last 10 years has exploded. New techniques, new-age wires, memory wires, all sorts of things are coming out. It’s cool to utilize that technology.”

That said, you still need a person to put a band and a wire on your teeth. That’s why Penna treats his patients to the latest gadgets, methods and instruments the orthodontic field has to offer. That includes wires made from lighter and more comfortable materials than the old ones.

“No matter how far you deflect that wire, the force will remain constant,” Penna says. “In the old days, with stainless steel, the further the tooth is out of position, the more force. Yikes. These wires now use a nice, light, gentle force. It’s not so bad.”

Penna also uses self-ligation brackets, or “speed braces,” which don’t need rubber bands or metal tie wires to hold the arch wire in place.

Over the past few years, Invisalign has dramatically altered the orthodontics field. Invisalign uses a series of clear plastic appliances that are custom fit to each user’s set of teeth. Each plate, worn for a couple weeks at a time, gently shifts the patient’s teeth.

Penna is one of a handful of local orthodontists to employ Invisalign Express, a less expensive alternative that streamlines slight corrections.

“Express is for those mild cases where you only need 10 aligners or less (5 months’ work). The lab fees are cut in half. For adults who absolutely won’t wear braces and have minor stuff, it’s a better option than a retainer with springs.”

It’s no mystery how Penna stays on top of developments in orthodontics. Continuing education is at the heart of everything he does. For the past 10 years, he’s taught  as a clinical associate professor in the orthodontics department of the University of Pennsylvania School of Dental Medicine.

“The simple acts of lecturing and interaction with residents forces me to be well read on all aspects of the profession,” he says.

 

 

Oral Surgery
Louis Rafetto
Labor Day weekend, night shift, Wilmington Hospital: It’s not a pretty place.

Louis Rafetto, on call as the oral surgeon, is staring down fractured jaws, displaced cheekbones and broken eye sockets. It’s a far cry from prying out wisdom teeth. That’s one reason Rafetto likes it.

“In there, you get to see people from every slice of society, people with few if any assets or support system, and then there’s people commuting down from Manhattan who pulled off the highway,” Rafetto says.

Invasive surgery and resetting jaws aren’t part of Rafetto’s day-to-day world, but the large scope of the specialty is what drew him to oral surgery in the first place.

“Part of the interest is what surgery does,” he says. “You’re making a pretty reasonable impact on people’s lives.”

For the past 28 years, he’s practiced in his Wilmington office, where he mostly performs routine wisdom teeth extractions. He is also on call at Wilmington Hospital, where he corrects a wide spectrum of diseases, injuries, and defects in people’s head, neck, face, jaws and mouths.

“It’s a challenge to be on top of so many different situations,” Rafetto says. “You have to know your limitations, learn how to ask for help when needed.”

Rafetto also places dental implants and performs the occasional bone graft or biopsy, which, unlike tooth extraction, has recently seen monumental technological shifts.

Thanks to a material called recombinant bone morphogenetic protein, surgeons no longer have to harvest bone from the patient’s body. “Instead, we can use this fluid in an absorbable sponge, put it in the site, and the bone will grow. Until the last couple of months, this has not been commercially available.”

The technique is used by surgeons in several practices, including spinal surgery. Rafetto, an examiner for the American Board of Oral and Maxillofacial Surgery and chairman of the American Association of Oral and Maxillofacial Surgeons, used his myriad contacts to learn the true scope of bone morphogenetic protein.

“I’ve gotten to know a lot of people who are involved in highly academic research processes,” he says. “So with the release of this BMP, I could call my friends in the research fields and get the scoop and see how it will work for me, and then be able to employ that in my practice.”

Rafetto likes to implement new techniques only when they can be used pragmatically to help his patients. In the most challenging cases, he relies on the wisdom of colleagues. After a young man from Haiti recently asked Rafetto to examine an unusual tumor in his upper jaw, Rafetto performed a total resection, from the orbital bone on down. Then he surgically rebuilt the young man’s face.

“Those are the cases where you find yourself stretched,” he says. “Before you go into the operating room, you call every person you know who does that sort of procedure and make sure what you’re doing is appropriate.

“As much as you need to learn the current way to do things, it’s equally important to maintain currency with what’s new and how to make the right kind of contacts. You have to know how to learn to learn.”

 

 

Endodontics
Dan Kreshtool
Root canal.

Read those words again. Try not to cringe.

In the American English lexicon, few phrases conjure the same degree of fear and preemptive pain than those two words.

Root canals take up the lion’s share of Dan Kreshtool’s day. He’s here to tell you, they’re not that bad.

Endodontics, the study of the pulp and nerves inside the teeth, is a very specific realm of dentistry. After 22 years of perfecting root canal therapy and some helpful advances in anesthetics, patients have significantly less to fear than they might expect.

Kreshtool, a third-generation dentist, says root canal therapy is more efficient than ever. And it’s virtually pain-free. Advances in equipment such as surgical operating microscopes have improved the process.

“These are the same microscopes being used by neurosurgeons and urologists that re-attach severed limbs,” Kreshtool says. “They allow me to preserve more good tooth structure and find hidden canals. That would directly translate to more comfort and more success and, even better, saving a tooth that you might not be able to save.”

Root canal therapy involves removing infected pulp by drilling into the tooth’s chamber, then scraping away infected tissue. “Pain aside, people used to talk about how it took so long, sometimes over several visits,” Kreshtool says. “Nowadays, partly because of the instrumentation, it takes way less time.”

More potent anesthetic always helps. Articaine anesthesia is a stronger version of the tried-and-true lidocaine, and it takes effect faster, which speeds therapy sessions and decreases pain.

“The best estimate we give people is a half hour to an hour in most cases,” Kreshtool says, “about the time it takes to fill a cavity.”

If anyone can streamline a root canal, it’s Kreshtool. He teaches in the graduate endodontic program at Temple University School of Dentistry in Philadelphia. Clinical root canal therapy is the main focus. “When you’re teaching something, you have to be able to explain things and show things,” he says. He is also a member of the American Association of Endodontics. At annual meetings in Philadelphia, he exchanges information with colleagues.

Still, no matter how routine root canals become, each case presents its own challenges, Kreshtool says. Teeth age, which shrinks the size of the canals. So an 85-year-old patient would have tiny canals, and maybe a crown on his tooth to boot. “Sometimes teeth just grow in a weird way,” Kreshtool says. “Roots may be curved or there are more than the usual number of roots.”

Then Kreshtool’s experience melds with his technology to overcome the obstacle. “It’s a comfort thing,” he says, even when his patient is still a little uncomfortable.

“It is difficult getting people over the fear,” he says. “And once they get to me, they’ve done the best they can just by agreeing to come to the office. Then I can show them it’s not that bad.”

 

 

Pediatric Dentistry
Rachel Maher
Rachel Maher knows the importance of first impressions.

For countless kids, she is the gatekeeper to the world of pain. She is the Alpha and the Omega. She is their first dentist. She is the enemy.

And that’s just for kids without cavities.

As one of few pediatric dentists in the state, Maher gets the kids general dentists don’t want to treat, thanks to a few tricks and her deft touch as a clinician.

“A lot of kids freak out somewhere else, but they’re more comfortable here,” she says. That should come as no surprise, considering Maher’s toy-filled waiting room, complete with Disney DVDs and a Jr. Pac-Man arcade game.

“A lot of times that atmosphere makes kids a lot less intimidated,” she says.

Still, Maher gets her fair share of screamers, with some patients coming to her as young as 8 weeks old. “If they scream for the pediatrician, they scream for a haircut, they’re probably going to scream for me.”

Especially when they have cavities, a situation that is growing at an alarming rate. Since 1999, 2- to 5-year-olds have experienced a 28 percent spike in cavities, surpassing asthma as the most common chronic childhood disease. “It has a lot to do with the amount of sugar kids are eating and bottled water, which doesn’t have the fluoride,” Maher says.

Most general dentists won’t see children until they are 4 or 5 years old—old enough to cooperate. By that age, Maher is already seeing a lot of tooth decay. Ever try drilling the tooth of a cantankerous 3-year-old? “I have to be the bad guy,” she says. “If I don’t do it, there aren’t too many people who will. We start seeing the kids younger, 2-, 3-, 4-year-olds with multiple cavities.”

Maher doesn’t have the latest in high-tech equipment, and gear for pediatric dentistry hasn’t really changed much in the past few years. Even if it had, the reactions of her patients probably wouldn’t. That’s why she incorporates elements of child psychology into her work.

“We have something called Tell, Show, Do. We tell, then show kids what we’re going to use. ‘This is what the tooth counter feels like,’” she says, taping the instrument onto her fingers. “Sometimes I use voice control. I’ll whisper, ‘The babies are sleeping next door,’ and they’ll stop fussing.”

Maher learned such techniques after years of exhaustive training. She attended University of Pennsylvania School of Dental Medicine. After completing her residency in Delaware, she went to specialty training in Cincinnati. She split time at a practice in Pennsylvania and at a pediatric externship at the Children’s Hospital in Philadelphia. The net result was 250 extra hours of training.

“There was a huge need for pediatric dentistry here in Delaware,” she says.

 

 

Periodontics
William Keller
Bugs play a leading role in William Keller’s life story.

He graduated from Ohio State University in 1980 with degrees in microbiology and dentistry. He studied bugs under microscopes and inside people’s mouths. Today, as one of the state’s leading periodontists, he deals with the bugs and bacteria that cause gum disease.

Keller witnesses staggering leaps in biomedical technology. His patients are lucky to have someone so knowledgeable.

Periodontics is the specialty that deals with the foundation of teeth, Keller says. “We’re talking about bone, gum and the ligament that goes around the tooth. If bacteria enters the area of the tooth and it’s not treated, then we’re dealing with diseases of the bone and gum.”

Most adults have some form of gum disease. Many of them have no idea.

The loss of damaged bone leads to periodontitis, or inflammation of the teeth support structure. That usually ends up in tooth loss. Prevention is the first step, Keller says, then comes removing bacterial plaque and rehabbing damaged bone structures.

Today teeth that are beyond saving can be replaced easily with dental implants.

“Now we’re at the next level,” he says. “Our practice has evolved.”

One big change deals with biomedical regeneration. Keller can regrow lost bone and gum. “We’re building it back to where it was originally,” he says.

Keller will take blood from a patient, then separate the platelets, which contain bone morphogenetic proteins. “We put these proteins back into the patient’s system to grow bone wherever we want,” Keller says.

About 50 percent of Keller’s job is replacing teeth with implant therapy, a process that has grown by leaps and bounds in recent years.

“Implants have evolved to the point where we can restore a tooth almost immediately,” he says. “It’s almost a one-day thing. A patient can walk in with no teeth and walk away with teeth. It’s amazing.”

Keller stays in the loop by constantly networking. In practice since 1980, a specialist since 1988, he has nurtured countless professional relationships throughout the country. He values the words of his colleagues over manufacturers of dental products. “You have to be careful with new technology because the manufacturers aren’t necessarily dentists,” he says.

As a fellow in the International Team of Implantologists, he attends seminars and continuing education lectures constantly.

“You’ve got to always learn. It never stops,” he says.

Keller came to Delaware in 1980 after graduating from Ohio State University. He practiced general dentistry for five years before heading to the University of Pennsylvania for his periodontics degree. He’s been back here, battling bugs, since 1988.

 

 

Oral Pathology
Robert Arm
During his rounds last summer, Robert Arm visited a patient at the Wilmington Hospital heart center. The patient was preparing for open-heart surgery. Down the road loomed radiation treatment and even more surgery. As if things weren’t bad enough, the patient’s teeth were in terrible shape.

An oral pathologist for Wilmington Hospital, Arm has many duties, including research, diagnosis and management of oral disease.

“People said, Why is a dentist seeing a heart patient? Many patients come in concerned and frightened about their conditions. And then another shoe drops. While you’re here, your bad teeth need to be taken care of. Before open-heart surgery, before radiation, we want to go to the mouth and avoid infection.”

Most of Arm’s day revolves around examining pre- and post-surgery patients for infectious lesions of the head, neck region and oral region. That also means copious observation, biopsies, re-biopsies, referrals and interviews.

Sometimes he’s busy questioning a patient. At others, he serves on a multidisciplinary tumor board that discusses options for a cancer patient. He may examine a patient who is undergoing post-radiation therapy. Then he’s off to Christiana Hospital to visit someone else.

His job is to investigate the causes, processes and effects of the diseases—plus a whole lot more. A lesion in the mouth of a pre-radiation patient can lead to infection. A lesion in the mouth of a post-radiation patient could’ve been caused by treatment, but oral symptoms often lead to larger diseases, and vice-versa.

“By looking at the mouth, we can see many signs of syndromes,” Arm says. “Bumps on the mouth could be a sign of gastro-intestinal polyps. Lack of saliva might lead us to yeast infections. Burning or tingling could be from diabetes.”

Often, Arm is working alongside primary care physicians and specialists. At Wilmington Hospital, he’s an important part of team treatment.

“Ever since I came, we had a concept of team treatment for every patient,” he says. “The head and neck oncology department has weekly meetings to treat patients. An interdisciplinary conference all works together. I work with the heart center, with the kidney transplant team. All the physicians, dentists and nurses see patients. And it’s nice to work in harmony. Here, dentists are treated as equals.”

It’s a good thing, too. Arm is a leading mentor in Delaware’s general practice residency and oral and maxillofacial surgery program. He estimates nearly two-thirds of the dentists in the state have come through the residency program at Wilmington.

Arm is a member of the Governor’s Commission on Community and Volunteer Services, the Access to Care Committee on Dentistry and the Authority in Radiation Protection. And he’s the former president of the American Academy of Oral Medicine.

That adds up to a lot of education, a lot of experience and a lot of connections.

 

 

Prosthodontics
Christopher Burns
Christopher Burns is the only maxillofacial prosthodontist in Delaware. He’s one of maybe 200 in the country. Sounds like a pretty important guy, no?

“Most of my patients have been through so darned much, by the time they get to me, I’m just a minor blip,” he says.

Burns creates custom prosthetic facial structures for oral and throat cancer patients from his private practice in Dover. Radiation and chemotherapy (as well as cancerous tumors) can damage living bone tissue in the jaw, ear and nose. Occasionally the entire support structure of a face is wiped out. Burns’ implants support maxillofacial prostheses and dentures.

“We’re mostly dealing with the after-effects of cancer treatment,” he says, “like if a large tumor gets removed or radiation therapy.”

Chemotherapy can damage oral tissue temporarily, Burns says. It may cause dry-mouth or soreness, but it recovers. The side effects of radiation, however, last forever.

One of Burns’ patients recently lost half of her lower jaw to tumor removal surgery. Without stability, range of motion in her jaw was severely limited. Instead of chewing in an up-and-down motion, the damaged jaw swung inward and collapsed.

Burns built a flange that rides on the outside of the woman’s upper teeth. Then he constructed a denture that rested on the flange. The result was a sturdy solution to a painful and awkward problem.

“So here’s this 87-year-old lady and her mouth works,” Burns says. “She swallows more effectively, she speaks clearly. It holds her jaw together and fills her cheeks out. I don’t know how it worked, but it did.”

Burns is being modest. He knows full well what he’s doing. He can rattle off the history of rubber prosthetics in 19th-century America and name the alloys in metal prosthetics from years prior. Surprising, perhaps, for someone who fell into prosthodontics “by accident.”

“I went to college with the idea of being a surgeon, and I was working in a genetics lab and making good money doing research projects,” he says. “One of the summer interns we had went to Georgetown Dental School and said it was fun, interesting, a lot of work. That was the route I wanted to take.”

Burns returns the favor by lecturing part-time at Polytech High School’s dental assisting program. He also takes 40 hours of continuing education a year to stay up on new techniques such as hyperbaric oxygen therapy for patients with radiation necrosis.

“You have to deal with the consequences of treatment,” Burns says.