James L Gutmann
Department of Restorative Sciences, Texas A&M University Baylor College of Dentistry, Dallas, Texas, USA

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• Diagnostic testing to determine the actual status of the dental pulp often finishing up as guess work for the clinician and more often than not treatment of some type is chosen because of "a hunch;" or the position of "let's do something that might work;" or is driven by economic pressures within the framework of today's dental practices. Efforts must be made to enhance diagnostic testing and standardize the concepts within the dental profession.
• MIE could also include the provision of a pulpotomy as a definitive procedure, but only if the status of the dental pulp can be determined much better than we do today. There are many patients who could be helped in this way, especially if there are financial constraints to having a root canal procedure.
• Knowledge of anatomical structures and their variations is essential so that from caries removal to root canal enlargement sound tooth structure should be preserved. Cervical root structure is at risk with excessive enlargement that is proposed with some techniques and results with the use of certain instruments.
• Development of techniques that minimize tooth structure removal for crown placement as the excessive use of porcelain-fused to metal crowns or for that matter, porcelain-only type crowns requires the removal of too much tooth structure that results in adverse pulpal responses.
• Considerations for crown lengthening procedures (and possible orthodontic extrusion) must be a priority before wholesale tooth extraction in cases of deep carious tooth margins, fractured tooth margins or margins violated by resorptive or perforative defects.
• Access openings must be crafted to preserve sound tooth structure; especially important is the prevention of gouging cervically, laterally or into the floor of the pulp chamber. However, access that is too restricted will impact greatly on what we do in certain situations.
• While judicious orifice location and careful canal penetration are essential, efforts should be made to minimize the excess removal of cervical tooth structure in the canal orifice through the use of Peeso reamers, Gates Glidden drills and orifice opening instruments. The literature indicates that loss of tooth structure cervically weakens the tooth and makes it susceptible to fracture.
• The use of Peeso reamers and Gates Glidden drills deep into the root canal should be abandoned in favor of minimally tapered rotary instruments (no larger than .06). The former instruments tend to straighten the canal, weaken the root walls and predisposing them to cracks and in some cases leads to irreparable defects, like root wall stripping defects.
• While the concept of larger apical sizes has received some literature credibility with regards to bacterial reduction, maintaining smaller sizes when possible (>20 ≤ 40) would seem desirable for preservation of radicular dentin in the majority of cases. It would then seem reasonable to develop better methods of canal cleaning and disinfection that can be used in the presence of retained, sound tooth structure.
• Techniques that favor ease of deliver of obturation materials thoroughly within the root canal with minimal application forces would tend to avert the possibility of root fractures and the placement of material beyond the confines of the canal orifice.
• The use of strong, well-placed, bonded core materials and a post (only when absolutely necessary) prior to crown placement would help to tie the components of the tooth together to resist both functional forces and occlusal leakage.
• Excellence in occlusal adjustments to prevent adverse functional forces is essential for all dental practitioners, including endodontists.

References

1.	Ericson D. What is minimally invasive dentistry? Oral Health Prev Dent 2004;2(Suppl 1):287-92.   [PUBMED]
2.	Ericson D, Kidd E, McComb D, Mjör I, Noack MJ. Minimally invasive dentistry - Concepts and techniques in cariology. Oral Health Prev Dent 2003;1:59-72.
3.	Ericson D. The concept of minimally invasive dentistry. Dent Update 2007;34:9-10, 12.   [PUBMED]
4.	White JM, Eakle WS. Rationale and treatment approach in minimally invasive dentistry. J Am Dent Assoc 2000;131(Suppl):13S-9.   [PUBMED]
5.	Murdoch-Kinch CA, McLean ME. Minimally invasive dentistry. J Am Dent Assoc 2003;134:87-95.   [PUBMED]
6.	Nový BB, Fuller CE. The material science of minimally invasive esthetic restorations. Compend Contin Educ Dent 2008;29:338-46.
7.	Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am 2010;54:249-73.   [PUBMED]
8.	Clark D, Khademi J, Herbranson E. Fracture resistant endodontic and restorative preparations. Dent Today 2013;32:118, 120-3.
9.	Clark D, Khademi J, Herbranson E. The new science of strong endo teeth. Dent Today 2013;32:112, 114, 116-7.

Correspondence Address:
James L Gutmann
Department of Restorative Sciences, Texas A&M University Baylor College of Dentistry, Dallas, Texas
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0972-0707.114342