Pre endo buildup

Multiple visit endodontics requires a good seal between appointments to allow medicaments to remain in place and to avoid further bacterial ingress. Additionally, it is important to have good integry of your restoration during every visit. Complete removal of caries  will remove the bulk of coronal bacterial reservations and a non leaking restoration will avoid leakage of irrigants out of the tooth and oral fluids into the pulp chamber.

Deep, subgingival restorations can be difficult to seal against a rubber dam as the gingiva often gets in the way of the dam septa. It is a good idea to restore these subgingival margins before commencing intracanal endodontics to have a better seal against the rubber dam. This is made even simpler if it is restore before the pulp chamber is accessed as there is less contamination from pulpal bleeding and less risk of extrusion of restorative material into the chamber.

The best way that I have found is to access the caries and caries free the margin all the way around the DEJ. Be careful not to exposure the pulp area. This can all be done before rubber dam placement. If the pulp is exposed, place some cavit over it to apply pressure to stop the bleeding and prevent extrusion of material into the chamber. You can preemptively apply cavit from the edge of the residual caries vertically to mimic and ideal access cavity. This is removed after the restoration to immediately have an ideal access cavity into a patent pulp chamber. Once caries freed, get a good seal against the cervical margin with a matrix band and wedge. Gingivectomy can be done before matrix band if the seal of the band is poor. Prepare the tooth and apply your desired restorative material. This can be a GIC because if a composite resin is applied you may end up replacing it anyway to have a uniform final restoration. Apply the restorative material into the cavity and use a flat plastic to place it against the matrix band and light cure. This can be done in increments. Final polishing of the interproximal contour should be done as sharp areas can stop the rubber dam from seating.

Once satisfied, Apply rubber dam isolation. Use a high speed diamond bur to widen the access and a slow round bur to clear the final caries and access the pulp chamber. You can then proceed as normal