Multiple access preps and poorly bonded composites
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From: Terry Pannkuk
Sent: Tuesday, March 17, 2009 6:40 AM
Subject: [roots] Today's Exam
I basically see this all the time and this is a case from today. When someone preaches conservative endo access and
restoration driven endodontics, this is what you get:
....this patient has had "on-and-off" subtle discomfort for the last 15 years when this work was done. I suspect that
the dentist who performed the endo "didn't want to mess up the new crowns". :)
.......multiple "ship-in-a-bottle" access preps filled with poorly bonded composites........several teeth thatt tested
"different" to percussion......radiographs showing numerous short-filled endos with likely missed canals and no evidence
of hydraulically filled lateral/accessory canals.......the bicuspid with the post was moderately percussion sensitive.
"Restorative-driven endodontics" usually means building a house on a foundation of sand.
Isn't it better to idealize the foundation then build the house?....or...maybe if you don't like the geological report
don't build the house at all! :) - Terry
Terry, I preach preservation of tooth structure, especially the PCD, not "preservation of porcelain"
There is a big difference.
Here is the concept of a stepped access for the fifty-billionth time.
It is not so different from the concepts in your drawings except that the expendibility of the restorative materials is
made explicit...as opposed to your drawings which appear to access a virgin molar... something I don't get to do very
much... John A Khademy
Your examples do not show direct line access to all orifices and you haven't established convenience form. This leads
to incomplete treatment and poor debridement. Some PCD has to be removed in strategic areas depending upon the case.
You can't make cardinal rules about access geometry and PCD preservation. When you compromise the access, you compromise
the endodontic case, and ultimately predispose the case to a higher probability of failure...or even worse a subtle
failure that aggravates the patient for decades..
Attached is a 5 canal maxillary molar case I started this morning. As you can see on the radiograph, the palatal canal
system is wide, anomalous and could even have a major apical bifurcation. The anatomy dictated the access extension and
the strategic extended removal of PCD in the area of the wide palatal orifice, the DB2 and the MB2. This patient is
never going to suffer or lose this tooth because of that dentin removal....but failure to look for those canals and
inadequate cleaning quite possibly could have condemned him to a a life of subtle discomfort described as being
"aware of the tooth". Incomplete access, leads to, incomplete endo and clinical mediocrity. Anatomy and convenience
form dictates the access. It is only the most exotic cases with aberrant anatomy that prevent that from being doable.
One question for you John Iím not going to debate the necessity of a larger access with you. I think Terry has that
covered. But I do have one observation:
It does seem that much of the ability to manage an access in the manner you describe, has to do with two factors:
(1) The ability to get sufficient light into the depths of the access - to properly illuminate the pulpal floor.
(2) Proper magnification (combined with high powered co-axial light) to be able to recognize these subtle structures.
The most recent statistics have shown that only a very small % of practitioners have a scope (or are likely to get one
in the near future). If this is the case, would it not be more valuable to enlarge the access sufficiently
(I DONíT mean bashing the floor) to be able to see better? Is this a fair tradeoff under the circumstances if they
donít use a scope? Many times it is a matter of illumination the ability to see. And for that you need a BIGGER
I think it is great that you can do this as conservatively as you do but if I try to teach this to my referrals, they
are gonna miss a LOT of stuff. In that aspect I strongly agree with Terry. Iíd rather that they were a little more
liberal with their access rather than conservative. If anything, most of the retreats I see are because of INSUFFICIENT
access rather than being bashed.
Can we really expect clinicians to do this routinely w/o a scope? - RobK
Good points. What should be clear is that we shouldn't be scoring points on who agrees with us. We should be thriving
on disagreement and the uncomfortable growth of intellectual disagreement. Philosophy is stengthened and validated on
We learn nothing by having people agreeing with us. I've probably made quite a few enemies by taking this to the extreme
online, something I'm very uncomfortable doing in real life.
Point/Counterpoint discussioins are really fun. I feel very strong debating endodontic access philosophy with John,
very inadequate debating microbiology with Fred, and I learned I didn't know crap when I tried to debate Cone Beam
Technology specs with Gary Henkel about a year ago.. :):):) - Terry
I don't recall the cone beam discussion, as I know just about enough to be dangerous on most subjects. But terry's point
is well taken. There is nothing wrong with professional difference of opinion. I've reversed my position a couple of
times based on frank dialogue. Just needs to keep the personal attack aspects out of the discussion. Procedures can be
done differently, and both get quality results. Terry hits a 9 iron, I hit a 7 degree driver because he is 8 clubs
longer than I am. Still has to go in the hole - gary