Recently there has been a push towards patient-centred outcomes in dentistry. This means we should treat towards outcomes that are important to the patient. Most patients want teeth that are aesthetic and free of disease and pain, and they want the teeth to be there forever.
In recent years, there has also been a push towards conservation of dentine during endodontic procedures in order to maintain as much strength in the tooth as possible. A recent study by Krishan et al showed that the concept of “straight line access” may lead to significant decreases in fracture resistance in premolar and molar teeth. Although this is a bench-top study, and a long way from a definitive link to outcome, to me it makes sense that if we are going to give the patient the longest lasting solution, then giving them the strongest tooth possible should be one of our primary goals.
In this case, a 22 year old patient was referred for endodontic treatment of the lower left second molar as an odontogenic cyst was to be removed and this would have resulted in loss of vitality of the tooth. There had also been some resorption of the mesial roots. Careful planning of the access allowed all canals to be treated without unnecessary removal of of “pericervical” dentine, the tooth structure that Clark and Khademi feel is the most important to be conserved. The pulp chamber was filled with amalgam and the access closed with composite resin.
I would warn that this approach is more clinically challenging to do well, and that when attempting to be conservative, that the procedure should be titrated. That is, if you need to prepare a canal, and your access isn’t allowing you to do this, then obviously, you need to remove further tooth structure in order to complete the endodontics.
Krishan R, Paque F, Ossareh A, Kishen A, Dao T, Friedman S. Impacts of Conservative Endodontic Cavity on Root Canal Instrumentation Efficacy and Resistance to Fracture Assessed in Incisors, Premolars, and Molars. JOE In Press.
Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am 2010;54:249–73.