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Medical Forum / General / Dentistry / October 2007RCT questions and the FAQ
Hi folks - I have read the FAQ, and see the information about trying to get a "good" endiodontist with a "conservative" approach. Of course, word of mouth is best, but I don't have that luxury unfortunately. The dentist of course can make a referral, which is a good start. Some questions for you all: * How do I make sure I am getting a good endiodontist with a conservative approach? What does "conservative" mean? Is it appropriate to ask for referrals? I'm told that "conservative" often equates to skill, regarding the amount of tooth area that gets drilled as part of the procedure. Correct? * My dentist told me that for back molar's (#18) in the U.S. it's pretty much standard operating procedure to get a crown due to the brittleness of the tooth caused by the RCT (acid?). However, my retired father in law - whom is a retired dentist from Brazil does not feel a crown is necessary *IF* the procedure conserves the tooth structure. Maybe it's different in the U.S. and the procedures in Brazil do not use the acid. (BTW, this is Sao Paulo, not the countryside, and they do use all the modern techniques). Here are some other questions: What is your approach to conserving the tooth structure? Do you use microscopes? Pinpricks to find the nerve? Your thoughts are welcome, and a special thank you to all the participants on this discussion. I assume you are using some web-site to access this newsgroup. The Usenet Newsgroup itself has no FAQ. Perhaps you might copy/paste the relevant section here. You will be rather dependent on your referral for a good endodontist. I doubt a lay-person would be able to compare anything beyond comfort and appointment times. I have no idea what a conservative endodotnist would be. As regards crowns,,,,,,,,,,,,,,, well that depends on how much tooth structure is missing once the RCT is done. I use CEREC technology myself, which allows me to bond porcelain directly to the tooth (without removing as much tooth structure. I, personally, do not cut a full crown for any teeth, unless a full crown already existed. I try to always leave as much of the outer walls of the tooth intact as possible. These "porcelain onlays" do not require as much removal of tooth structure, but take a bit longer for some dentists to prepare. Dentists are generally taught in dental school to automatically crown any tooth with a RCT. Most dentists will subsequently learn that this is not necessary if a lot of tooth structure remains.  Signature/ Amatus / > Hi folks - I have read the FAQ, and see the information about trying > to get a "good" endiodontist with a "conservative" approach. Of [quoted text clipped - 22 lines] > Your thoughts are welcome, and a special thank you to all the > participants on this discussion. > I assume you are using some web-site to access this newsgroup. The Usenet > Newsgroup itself has no FAQ. Perhaps you might copy/paste the relevant [quoted text clipped - 14 lines] > automatically crown any tooth with a RCT. Most dentists will subsequently > learn that this is not necessary if a lot of tooth structure remains. Only to add that while crowning is not necessary, some restoration that covers the cusps is generally necessary. An endodontist should not IMO make a minimal opening into the pulp, as (esp. back at the second molar) visibility is difficult, and you must be sure the entire pulp chamber and all canals are found and thoroughly instrumented. Even if a small access cavity is drilled, most teeth requiring root canal are already pretty beaten up, and these teeth need to withstand a lot of biting pressure. I've seen too many of these teeth restored with amalgam or composite without covering the cusps later fracture vertically, and the tooth is lost. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 I would say we are more conservative on anterior teeth. Less of these get full coverage. I think the success rate for an anterior tooth after RCT is about the same with or without the crown (assuming at least half the original tooth remains. For posterior teeth, if the existing excavation (for both caries and pulp access) is less than one third the width of the tooth (seldom seen), I will leave the natural cusps tips intact, and bond porcelain into the hole. Most RCT *molars* get my modified onlay prep. Ask Newbie. Signature/ Amatus / >> I assume you are using some web-site to access this newsgroup. The >> Usenet Newsgroup itself has no FAQ. Perhaps you might copy/paste the [quoted text clipped - 29 lines] > > Steve Thank you all for your very thoughtful replies. The father in law wants to see the x-rays, so I'm stopping by the doc's to pick them up tomorrow. I now understand what conservative means - basically not drilling away healthy tooth. Thank you for that. I will try to post the x-rays for further discussions. Without such, we're kinda shooting in the dark. The father in law is a very skilled dentist. I My wife always gets comments on his great work .. She always tells me she gets the same speech from her dad's dentist friend about "best work he's ever seen" , etc. I value and respect his opinion, and so did his colleagues. It's amazing how those dental/artistic skills translate to in home projects like flooring, woodworking, painting and the such. ;-) I just don't want the OP to think that a crown on a molar that's had a root canal is a bad thing, which is the flavour that I got after reading all of the posts. Keep in mind, a crown in such a situation is generally considered the standard of care in North America. I want the OP to understand that just because you reduce more tooth structure with a crown, doesn't make it a wrong treatment choice. As AC pointed out, many dentists do not feel as comfortable doing an inlay/onlay (preparation and bonding) as they do for a crown. So, in the long run, if you have a crown done by such a dentist, the patient is probably far better off than having that same dentist do an inlay/onlay. I would be curious to know if the OP's wife has any crowns, veneers, or onlays, given the comments she has received. John It also depends on what type of crown we are talking about. A FGC prep can taper down to the gingival with very little tooth removed. Much different than some all porcelain jobs that may whack off 1.5 mm or so. :-) D > As AC pointed out, many dentists do not feel as comfortable doing an > inlay/onlay (preparation and bonding) as they do for a crown. So, in the > long run, if you have a crown done by such a dentist, the patient is > probably far better off than having that same dentist do an inlay/onlay. >> John Have you heard of the "mini" crown ? Advocated by Ross Nash. It's basically a 360 degree veneer. 0.3 - 0.5 mm reduction. Have made some of these using Chromatech porcelain and bonding them with Calibra. They look great. You can also make Captek crowns with a knife edge margin on molars, a mini chamfer works well too. >It also depends on what type of crown we are talking about. A FGC >prep can taper down to the gingival with very little tooth removed. [quoted text clipped - 11 lines] > >>> John > You can also make Captek crowns with a knife edge margin > on molars, a mini chamfer works well too. Did some Capteks years ago. I've seen the porcelain chip down to the gold coping. Not a big fan. JME, Steve >> You can also make Captek crowns with a knife edge margin >> on molars, a mini chamfer works well too. [quoted text clipped - 4 lines] >JME, >Steve If you are talking about the knife edge margin, sure that can happen. You can also have a metal margin with Captek. Occlusal reduction should be about 2.0 - 2.5 mm. Don't forget the secondary reductions for lower buccal, and upper lingual. <molars> Am now largely doing long bevel or chamfer preps. Sometime use these for anteriors, depending on the case. Capteks do very well for both lower and upper 2nd Bis. Tend to use all ceramic for upper 1st Bis Most anteriors now get Chromatech all ceramic stacked porcelain, bonded with Calibra. Am using Capek as my standard PFM and have placed hundreds of them. Many 3 unit bridges too. The major advantage is that since the coping is not cast, there is an extremely accurate fit. IIRC ~40 micron w/o die spacer. IOW no internal adjustments are required. Additionally the coping is of *uniform thickness*, something that cannot be readily achieved by waxing. Very little opaquing material is required. When used with the newer porcelains a very life-like result is achieved. With a few minor mods to your preps, Captek can be an excellent restoration. Lab fee is a bit higher, and a "certified" Captek lab should be used. >I would say we are more conservative on anterior teeth. Less of these get >full coverage. I think the success rate for an anterior tooth after RCT is [quoted text clipped - 5 lines] >leave the natural cusps tips intact, and bond porcelain into the hole. Most >RCT *molars* get my modified onlay prep. Ask Newbie. Which is quite interesting to see. Basically the pulp chamber is included in the "onlay" prep. The restoration looks somewhat like a mushroom. With cuspal coverage and the internal bonding of the machine milled porcelain restoration, teeth restored by this method appear to have a very good chance of lasting many, many years. I wouldn't hesitate to let AC restore any of my molars. Hello, I haven't heard of an "aggressive" or "conservative" endodontist before. Usually you would just want one that does a good job! ;-) > * How do I make sure I am getting a good endiodontist with a > conservative approach? What does "conservative" mean? Is it > appropriate to ask for referrals? I'm told that "conservative" often > equates to skill, regarding the amount of tooth area that gets drilled > as part of the procedure. Correct? Usually I think general dentists are more often referred to as "conservative" in approach. I would think a conservative dentist has your best interests at heart and is aiming to preserve natural tooth structure as much as possible where indicated when it comes to any type of restoration. You can never grow your natural tooth back so often it's best to try to preserve as much of it as you can. Unfortunately, it's sometimes hard to find a dentist like this. See what Dr. Gordon Christensen has to say about this: http://aadc.org/files/I%20Have%20Had%20Enough.pdf With endodontists, I believe that most like to preserve as much of the crown structure remaining as possible, but not at the expense of access and visualization. When doing the access preparation for a root canal, you want to have straight line access to the canal system. If a part of the tooth gets in the way or compromises that, it generally makes the procedure more difficult and as a result could decrease the chances of a good result. I'm not sure if those rules apply to laser endodontics (maybe someone else can comment there) since I think they use a flexible laser filament (??) , but it's a general rule that is followed by most dentists I believe. > * My dentist told me that for back molar's (#18) in the U.S. it's > pretty much standard operating procedure to get a crown due to the [quoted text clipped - 4 lines] > Brazil do not use the acid. (BTW, this is Sao Paulo, not the > countryside, and they do use all the modern techniques). With a second molar, I would probably lean on getting a crown rather than not since I find the chewing pressure on posterior teeth quite high. The amount of pressure you can apply on a tooth back there necessitates something that can withstand it. With root canals, an access hole is made down the central area of the tooth making a tunnel into the root system. That weakens the remaining tooth structure tremendously. BTW, a dentist likely can't tell just by an xray alone whether or not a crown is needed. At minimum, for a molar that has been root canaled I would get some restoration that covered all the cusps as in an onlay or crown to help hold the tooth together and avoid fracturing. On the flip side, I have seen some people walk around with big fillings on root canaled teeth in the back, and they have done fine for years and years. It really depends on how much tooth is left, how strong it is, how strong the filling/bonding is, and how much you want to gamble on whether it all holds together. I'm not a big gambling person so I figure why take a risk so I prefer crowning or onlaying root canaled posterior teeth when it is indicated. > Here are some other questions: What is your approach to conserving the > tooth structure? Do you use microscopes? Pinpricks to find the nerve? I conserve tooth structure by minimizing the size of my preparations where possible. If a cusp appears to be solid and has good support, I'll leave it and work around it. With endodontic access I will try to keep my access preparation limited to the minimal size required for good access and visualization. I won't go crazy with veneers and crowns when I don't feel they are necessary. Usually dentists don't like to remove good tooth structure if they can help it. Microscopes and loupes definitely offer an advantage. I don't believe pinpricking makes anyone a conservative dentist. :-) > Your thoughts are welcome, and a special thank you to all the > participants on this discussion. If you aren't too far from Curitiba, I would suggest visiting Dr. Newton Fahl Jr. http://www.fahl.com.br/ This guy is an amazing dentist. I sat in on a lecture by him, and I was blown away with his skills. He is a master of composite dentistry! I highly recommend him. He also would likely know of a good endondontist in your area. Zzzdentist dentalminds.com |
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