Friday, April 25, 2008

Pretreatment - Worth the Effort?

Pretreatment involves preparing a tooth for Endodontic treatment. Many endodontically involved teeth are heavily broken down or carious. Some involve deep fractures, subgingival proximal caries or faulty margins. The need for proper isolation of a tooth during Nonsurgical Endodontic treatment demands the use of rubber dam. Adequate isolation can only be achieved when the portion of the tooth to be clamped is in a reliable condition. Failure to adequately pretreat a tooth can result in contamination of the working area through rubber dam leakage, clamp disengagement or loss of reference points. Pretreatment does require extra effort on the part of the dentist and slight added expense to the patient. However, this is more than made up in the ease of treatment, asepsis of the working area both during and after treatment. It also gives reasonable assurance that the tooth will be protected until it is restored.

Types of Pretreatment

1. Removal of all caries and defective restorations

In order to consider any tooth for endodontic treatment, we first must determine if it is restorable. There is nothing more embarrassing for clinician than to complete endodontics through a crown, only to find that the remaining tooth is not restorable and must be extracted. This can be prevented by removing all caries and defective restorations from the tooth and examining for adequate remaining tooth structure. If you are satisfied that the tooth can be restored, move to step 2.

2. Gingivoplasty/Gingivectomy with Electrosurgery or Lasers

In some cases, caries, fractures or defective restorations are sub-gingival. Teeth with caries is just below the gingival crest can occasionally be treated by judicious use of elctrosurgery or gingivoplasty where hyperplastic or excessive gingival tissue is removed to allow placement of a rubber dam clamp. In severe cases, such as those with muco-gingival involvement, those that require osseous recontouring or apical repositioning, the patient may require referral to a Periodontist before initiating endodontic treatment. There is no point in treating the case endodontically if attainment of proper biologic width and a healthy periodontal condition is not achievable.

3. Reinforcement of the remaining tooth structure

Sometimes a tooth will be so broken down that insufficient solid tooth remains to use a rubber dam clamp. On other occasions the clamp may be able to be placed, but the post operative fragility of the remaining tooth poses a serious risk of vertical or cusp fracture. (Loss of a reference cusp during treatment can mean inaccurate working lengths.) In those cases, reinforcement of the tooth is necessary.

For many years banding of teeth with copper or orthodontic bands was the method choice. With the development of deeper curing light cured composites and fast setting bonded core pastes, banding of teeth has become less common. However, the copper band offers one advantage that these other technologies do not… the ability for the rubber dam clamp to securely engage the soft copper of the band and not come loose. As much as I dislike taking the time and trouble to place a copper band on a tooth (a well fitting band can take 20 min. or more to place), I invariably love the results. The case is much easier to treat, isolation is easily achieved and the rubber dam remains secure throughout the treatment. The tooth also has much less chance of post-operative loss of seal or fracture. The properly contoured copper band can also serve as an excellent temporary restoration in cases where patients cannot afford to have the tooth restored immediately, or where other, more important treatment dictates that the tooth remain unrestored for a few months.

By : Robert Kaufmann DMD MS (Endo)