I had an instructor in dental school who jokingly told his class, “If you want to have patients who never get cavities, the solution is simple. Extract every other tooth.” While it’s an odd statement, there is a lot of wisdom in it. Generally, creating an environment where a tooth is cleanable on all surfaces, food cannot get stuck and plaque cannot hide, the odds of not getting cavities, or at least fewer cavities rise in your favor.

So, going off on an Andy-Rooney-style rant. Did you ever notice that recurrent decay around a crown margin happens interproximally most of the time? Do you know why? Well let’s answer some questions.

What part of a tooth is the most difficult to prep?

What part of the tooth is usually carious to begin with?

What part of the tooth is the most difficult to isolate?

What part of the tooth is the most difficult to clean cement from?

It's always the same answer. It's the darn interproximal.

I would say we spend a huge amount of time dealing with the interproximal area on our preps. In addition, we spend huge sums of money to deal with them as well. We buy lasers, cord, cord packing instruments, hemostatic agents, and a slew of other products just to deal with this 3-mm-wide area.

Let's think about this for a minute. Our challenges are many. This is the area where decay usually abounds and its toxins cause the non-keratinized gingival Col to become inflamed and bloody, making it difficult to visualize the tooth structure. The likelihood is high that the previous restoration or the decay that is present went subgingivally. Further exacerbating the problem. So what do we do?

Well, there is no easy answer. Certainly not one that leads to a solution every time. Remembering back to my dental school days, we were given a bur kit with a chamfer bur, a football diamond for occlusal reduction and a flame-shaped bur to break contact. I have found myself regressing to those days. No longer do I use solely a diamond chamfer bur for everything. I now actually use that flame-shaped bur first. I open the contact and use that bur to gently clean up the gingival area. I will shape my margin and remove any inflamed soft tissue, within reason, of course. Then I move to the opposite interproximal and do the same. This causes bleeding and it's fine at this stage. Now I move to the occlusal reduction as well as any necessary buccal and lingual reduction. Now I go back to the interproximal to refine it. By this time the bleeding has stopped and generally I have a better visual field. Now I can decide if I need the laser, cord, etc.

It's not a magic pill but by changing the sequencing of my prep, I am able to do the job I need to do without tiptoeing around to try to not create bleeding. Do it first and effectively and let the body respond while you are doing other things. It sure beats seeing the patient a couple of weeks before and extracting the adjacent teeth.