Caries and isolation management
Jon Richards DDS MS
This is quite an ordinary upper 1st molar initial case, but I think it demonstrates a way to manage the operative field in order to maximize the chance of success.
We have known “since the beginning” that preventing the ingress or reinstroduction of microorganisms into the canal system is a significant component of long term success. When a carious lesion is present that involves a large portion of the tooth, and extends deep sub-gingivally, this can present some problems.
Every case should start with the placement of a rubber dam. In this case, the retainer was placed on the tooth distal to the treatment tooth. This allows for 1) better visibility, and 2) placment of a matirx band when needed.
It is critical to remove all caries prior to placing a temporary or permanent restoration. Placing a resin or glass-ionomer partial buildup helps contain the irrigant and prevent leakage under the dam. Sodium Hypochlorite in the patient’s mouth is not only harmful, but inconsiderate and unprofessional.
After confirming resolution of the patient’s symptoms, I placed a bonded amalgam core. Amalgam is especially useful in these situations where the margin is deep and dentin bonding is less than ideal. Additionally, high-volume bulk composite is known to undergo proportionate volumetric shrinkage- not a good situation with poor bonding. This can lead to leaking margins and long-term failure. Amalgam on the other hand is very stable dimensionally, has excellent compressive strength, and will not flex under load unlike its resin counterpart. It is much more forgiving when it comes to deep proximal boxes and has less of chance of voids in critical areas. The patient was advised to proceed with the full overage crown just as soon as possible.