WHY ARE SOME RESTORED TEETH SENSITIVE
Use the following steps to prepare the tooth and reduce the possibility
of exposing the pulp:
Plan the external cavosurface margins of the restoration, and cut
the tooth preparation as though the tooth were a sound tooth. This
is contrary to what is usually taught.
Remove any superficial caries or caries-undermining enamel as
soon as the initial preparation outline is established. Leave the deeper
areas of the caries intact until the last step in the tooth preparation
When removing the deep portion of caries, exercise extreme caution to avoid exposing the pulp. Water spray disguises the cutting with
the bur. Significant sound from air blowing or the HVE makes the RPM
of the bur difficult to determine. Turn off both the air and water when
removing deep caries. The myth that cutting without water will overheat the tooth has been disproven—as long as the cutting is gentle
Use careful, slow bur rotation augmented with a sharp spoon excavator to remove the soft dentin.
Now comes the most difficult and least predictable part of the deep
tooth preparation procedure. Assuming the tooth is alive, the dentin
will have a pink color as the pulp is approached. The dentist must
make a clinical judgment about when to stop removing dentin. One
may leave tooth structure that is hard when scraped with a spoon
excavator but is still discolored, awaiting subsequent disinfection and
Based on research and my personal experience, I strongly suggest
that a live tooth is much better than one that has been treated
INDIRECT PULP CAP TECHNIQUE
The indirect pulp capping techniques (lining or basing) described
below can be used for typical direct, resin-based composite
Desensitize and disinfect the entire tooth preparation. Numerous
chemicals have been suggested to accomplish these goals, including
chlorhexidine, benzalkonium chloride, sodium hypochlorite, glutar-
aldehyde, and others.
Research at Clinicians Report Foundation (CR) has shown that
glutaraldehyde accomplishes both desensitization and disinfection
of tooth structure predictably and effectively. 1 Representative brands
are G5 from Clinician’s Choice, Gluma from Kulzer, Glu/Sense from
Centrix, and Micro Prime from Danville.
The solutions are applied by dipping a microbrush in the solution
placed in a dappen dish, only dampening the microbrush, and carefully
applying the solution to the tooth preparation surface. Allow the solution to stay on the tooth for one minute, and then repeat the procedure
for one more minute. Do not wash it off. Suction off the solution with
high-velocity suction. Do not let the solution get on the soft tissue,
because it will irritate the tissue.
Place the liner or base of your choice. CR surveys show that the
most popular type at this time for indirect pulp capping is resin-modified glass ionomer (Vitrebond Plus from 3M, Fuji LINING LC
from GC America, and TheraCal LC from Bisco Dental). However,
many others have been shown to be successful as well.
Bond with the technique of your choice. This may be total-etch,
selective-etch, or self-etch. All have been shown to be acceptable
If using total- or selective-etch, glutaraldehyde must be placed
again. The first application of glutaraldehyde was placed to desensitize
and disinfect the dentin before the liner or base was placed, and it is
now active under the liner or base. Then, the preparation was acid-etched and washed, thus washing off the first application of glutaraldehyde. The second glutaraldehyde application is only a brief rubbing
of the moistened microtip on the prep for a few seconds. Suction off
the excess glutaraldehyde.
If using self-etch, the second application of glutaraldehyde is not
necessary, since the tooth prep was not washed off.
Complete the bonding procedure.
Place the restoration of your choice.
INDIRECT RESTORATION TECHNIQUE (CROWNS, ONLAYS)
Use the following technique to remove deep caries for indirect res-
torations, such as crowns and onlays ( figures 2–4):
As with the direct tooth preparations above, prepare the tooth
for the crown or onlay as though it has no caries or previously placed
Remove the superficial caries as described above, remove the
previous restorations, and carry out the same procedure described
above for an indirect pulp cap. Apply the glutaraldehyde as above in
two one-minute applications. These tooth preparations for indirect
restorations are primarily in dentin. Unless some enamel is present,
there has not been an enamel etch and wash, so there is no need to
make a second brief application of glutaraldehyde.
Place fillers ( for small voids in the prep) or buildups (if more than
one-half of the coronal tooth structure missing) in the tooth preparation voids.
Finish the tooth preparation.
Make a conventional impression or scan the preparation.
Figure 2: This patient
was extracted, and
the other three teeth
treatment as described
in this article.
Continued on p. 109