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Dental Practice: What clinical guidelines can you offer for restoring an endodontically treated tooth? Dr. Whitehouse: Restoring endodontically treated teeth do not, in my opinion, fall into a single category but must be assessed case by case with an MID approach. For example, if a tooth requiring a root canal due to decay on the facial aspect could be restored with a composite or an inlay, the tooth would be much stronger than if a crown were placed. The same goes for an anterior tooth with proximal decay. Too many anterior lateral incisors and lower incisors have broken because the crown preparation took away valuable supportive structure. A glass post alone may be beneficial in these cases. When dentistry comes from a paradigm of crowning all root canal treated teeth, it takes time and focus to adopt a less invasive approach. There are many teeth that I do not crown but, instead, selectively place the restoration that will enable the tooth to survive the longest, often with onlays. In fact, I rarely place crowns; I usually use the remaining good tooth structure and an onlay and, perhaps, a post to accomplish this outcome. I do believe that a prefabricated post may be more important, in some cases, than crowning teeth. This is because the reduction for the crown robs the tooth of some of its inherent strength. Bondable posts along with onlays, if appropriate, are the most common restorations for root canals in my office; but placing no onlays/crowns is common, also. MID seeks to find the best long-term outcome for the remaining tooth structure; its aim is not to compromise that structure by uniformly providing a crown for teeth that have undergone a root canal, however financially profitable such a policy might be. Dental Practice: You advocate tunnel preps from the labial surface. What are your thoughts on tunnel preps that approach the lesion from the occlusal? Dr. Whitehouse: Tunnel preps reveal interproximal cavitated lesions for restoration, thereby conserving the integrity of the marginal ridge and, thus, the strength of the tooth. I prefer entering from the facial aspect, rather than the occlusal, for better visibility and for the protection of the proximal tooth. Using a Waterlase affords me a preparation that leads to a good bond and eliminates bacteria. Often, no anesthetic is needed. An end-cutting carbide bur will afford the same preparation. Approaching the lesion from the occlusal is standard procedure for some dentists and works well for them. When that approach is taken, I find it more difficult to know how much tooth structure to remove and where to remove it, because an x-ray does not provide a depth. With the facial approach from the line angle, no occlusal preparation is needed, especially if no decay is present. I find that injecting glass ionomer into the preparation works well.
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